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HealthSmart Medical Registration Form
We are accepting new patients! Fill out the form below to add your name to our registration list. You may add up to 5 people. We will contact you when appointments become available.
* Indicates required question
Email
*
Your email
Which medical clinic location would like to register for?
HealthSmart Scarborough
HealthSmart Medical Stouffville
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Contact Person - First name, Last name
*
Your answer
Phone number
*
Your answer
I would like to register the following people.
Below, please fill in the information for up to 5 people you would like to register.
Person #1 First Name, Last Name
*
Your answer
Request Male Dr. or Female Dr.
*
Male Doctor
Female Doctor
Person #2 First Name, Last Name
Your answer
Request Male Dr. or Female Dr.
Male Doctor
Female Doctor
Clear selection
Person #3 First Name, Last Name
Your answer
Request Male Dr. or Female Dr.
Male Doctor
Female Doctor
Clear selection
Person #4 First Name, Last Name
Your answer
Request Male Dr. or Female Dr.
Male Doctor
Female Doctor
Clear selection
Person #5 First Name, Last name
Your answer
Request Male Dr. or Female Dr.
Male Doctor
Female Doctor
Clear selection
Submit
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