BC Patient Enrolment Form

See a Doctor 100% Covered By Your

BC Health Card

We'll ask you a few questions to match you with a doctor. All your information is kept strictly confidential and 100% secure.
What Is Your Name? *

First Name Last Name
What Is Your Email Address? *
example@example.com
Phone Number *
Please enter a valid phone number.

Placeholder Email
BC Health Card Number

This allows us to offer your appointment for free. If you don't have this handy you can provide it before your appointment.
Address *

Street Address

Street Address Line 2

City Province

Postal Code

What's the main reason that you want to see a doctor? *
*By requesting an appointment, you agree to Rocket Doctor’s Terms and Conditions, Email Communications Policy, Informed Consent, and Privacy Policy.
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Should be Empty:

BC Health Card Number