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Family Doctor Waitlist Registration
Welcome to our Family Doctor Waitlist Registration form. By completing this form, you will be added to our waitlist for assignment to a family doctor at our clinic. Please fill out the required fields below to ensure we have accurate information to assist you effectively. Once submitted, our team will contact you as soon as possible regarding your enrollment and appointment scheduling.
* Indicates required question
Email
*
Record my email address with my response
Full Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Phone number
*
Your answer
Email Address
*
Your answer
Please provide your valid OHIP card information (card number, version code, expiry date)
*
Your answer
Have you been a patient at our clinic before?
*
No
Yes
Required
If you choose "Yes", Please provide the Doctor's Name
*
Dr.Shih
Dr.Raddatz
Dr. Leszko
Dr. Le
Others
No family doctor before
Do any of your family members also interested in finding family doctor?
*
Yes
No
Required
If you choose "Yes", Please provide the Full name, Date of Birth, Relationship to you, and OHIP information. If you choose " No", please put down "Not Applied".
*
Your answer
Please briefly explain why you are considering switching or finding family doctors.
Your answer
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