Patient Demographic Form
Always Care Health Clinic Virtual Appointment Registration
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Email *
Full name as shown on health card/government id *
Full address, including postal code *
Phone number *
Ontario health card number & version code *
Date of Birth *
MM
/
DD
/
YYYY
Reason for appointment *
Appointment Date (Must be a Saturday) *
MM
/
DD
/
YYYY
Preferred appointment times (check all that apply) *
Required
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