New Patients Looking For A Family Doctor

Please submit your details below and one of our staff will contact you. Fill in a SEPARATE form for EACH family member who wants to register

Contact Form

Name

Full Name ( EXCATLY As It Appears On Your HealthCare )

Gender

Date Of Birth

EXACT FORMAT: YYYY-MM--DD

Phone

Ideally Cell Number

Want Address Name

Full Address

HealthCard Details

10 Numbers AND 2 letters, eg.012345678 AB

Medical Conditions

List Of Previous/Current Medical Conditions And Operations ( eg. Depression, Sinus surgery )

Current Regular Medications

List Of Current Regular Medications With Dosing ( eg. Eltroxin 50mcg once daily ) - We Do NOT Prescribe Stimulatns/Narcotics ( eg. For ADHD/Chronic Pain)

Weight In Kilograms

Height In Centimeters

Reason You Want A Doctor

( eg. Specigic Medicine ) And The Name Of The Doctor ONLY If You've Been Referred To A SPECIFIC One. We Do NOT Assess For ADHD

Make a Call

+1 (416) 555-0123

Send Email

Info@truekindclinic.com

Visit a Clinic

123 Main Street, Toronto, ON, Canada