Patient Registration

Every field on this form is mandatory*. If you do not complete one section, you will not receive an appointment. *If you are booking online please ignore the "Location" section.

Location (if you are in-clinic)*

Last Name*

First Name*

Gender*

D.O.B (dd/mm/yyyy)*

Payment Method

Health Card

Private Pay

OHIP No. (First 10 Numbers)*

Version Code (Last 2 Letters)*

Phone Number*

Email Address (we usually use this to notify you about results)

Emergency Contact* (put x if it's the same as above)

Symptoms

If none apply, select General (Other)

Group

If you're with family or want to be seen as a group, check this box.