DREAM KIDS CLINIC

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DREAM KIDS CLINIC

NEW PATIENT REGISTRATION

Email *

Patient Name *

First - Middle - Last

Date of Birth *

Month / Day / Year

Gender *

Male

Female

Home Address *

Full Address (ex: 479 Dundas St. W, Oakville ON, L6M 1L9)

Primary Contact Number *

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

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:

Does Your Child Have an Existing Doctor? *

My child has (or previously had) a family medicine doctor or pediatrician for routine check-ups and vaccines.

My child is a newborn and has no primary care doctor.

We recently moved to Ontario, and have no primary care doctor for our child.

How Did You Find Our Clinic? *

Online reviews from Google Search / Google Maps.

Recommendation from someone I know.

Social media post.

Other

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