Patient Enrolment and Consent to Release Personal Health Information
I would like to register with:
*
Please Select
First Available Physician
Dr. Grace Liao
Dr. Victor Liao
Dr. Amy Liao
Name
*
First Name
Second Name
Last Name
Date of Birth
*
/
Year
/
Month
Day
Date
Sex
*
M
F
Mailing Address
*
Street No. and Name or P.O. Box
Apartment #
City
State / Province
Postal Code
Residence Address
*
Same as mailing address
Not the same as mailing address
Residence Address
*
Apartment Number
Street No. and Name or Lot, Concession and Township
City
State / Province
Postal Code
Please send notices from the doctor's office to me by:
*
email (default)
Email Address:
*
example@example.com
Health Card Number
*
Version Code
*
The two letters after the health card number
I would also like to enroll my child (under 16) or a dependent adult with the doctor
*
Yes
No
Dependent 1
*
First Name
Second Name
Last Name
Health Number
*
Version Code
*
Sex
*
M
F
Date of Birth
*
/
Year
/
Month
Day
Date
I am this person’s
*
parent
legal guardian
attorney for personal care
Mailing Address
*
Same as above
Not the same as above
Mailing Address
*
Apartment Number
Street No. and Name or P.O. Box
City/Town
State / Province
Postal Code
Residence Address
*
Same as above
Not the same as above
Residence Address
*
Apartment Number
Street No. and Name
City/Town
State / Province
Postal Code
I would like to enroll another dependent with the family doctor
*
Yes
No
Dependent 2
*
First Name
Second Name
Last Name
Health Number
*
Version Code
*
Date of Birth
*
/
Year
/
Month
Day
Date
Sex
*
M
F
I am this person’s
*
parent
legal guardian
attorney for personal care
Mailing Address
*
Same as above
Not the same as above
Mailing Address
*
Apartment Number
Street No. and Name or P.O. Box
City/Town
State / Province
Postal Code
Residence Address
*
Same as above
Not the same as above
Residence Address
*
Apartment Number
Street No. and Name
City/Town
State / Province
Postal Code
Section 3 – Signature
I have read and agree to the Patient Commitment, the Consent to Release Personal Health Information and the Cancellation Conditions. I acknowledge that this Enrolment is not intended to be a legally binding contract and is not intended to give rise to any new legal obligations between my family doctor and me.
I am signing on behalf of (check all that apply)
*
myself
child(ren)
dependent adult(s)
My Last Name
*
My First Name
*
Signature
*
Clear
Date
*
/
Year
/
Month
Day
Date
Home Telephone Number
*
Work Telephone Number/Cell Phone Number
Please enter a valid phone number.
How did you hear about us?
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Internet (e.g. Google)
Other
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