DREAM KIDS CLINIC

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

DREAM KIDS CLINIC

Walk-in Urgent Care New Patient Registration

Email *

Patient Name *

First - Middle - Last

Date of Birth *

Month / Day / Year

Gender *

Male

Female

Reason For Urgent Care Visit *

Home Address *

Ex: 479 Dundas St. W, Oakville ON, L6M 1L9

Primary Contact Number *

Please include dashes (ex: 905-286-1134)

Secondary Contact Number *

Please provide a secondary number in case we are unable to reach you for urgent matters, such as abnormal lab or imaging results.

Please include dashes (ex: 905-286-1134)

Patient Health Card Number *

10 digits + 2 letter code (ex: 9052863411-DK)

Private Health Insurance *

Do you also have private insurance coverage for your child? Certain medications are not covered by OHIP. We are requesting this information, so our pediatricians can provide appropriate treatments with minimal cost to your family.

Yes, my child is also covered under a private insurance plan.

My child has OHIP coverage only.

I am not sure, but will find out before our appointment.

Other:

How Did You Find Our Clinic? *

Positive reviews from Google Search / Google Maps.

Recommendation from family member or friend.

Social media post.

Other

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms