Patient Enrolment and Consent to Release Personal Health Information
I would like to register with:
*
Please Select
Dr. Victor Liao
Dr. Amy Liao
Please note that Dr. Grace Liao is on maternity leave and another doctor at our clinic will be taking care of her patients during this time.
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?
Social Media (e.g. Facebook, Instagram, etc.)
Internet (e.g. Google)
Other
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