Mississauga Clinic Document

Register As A Family Patient

Please fill this form completely

First Name:

Last Name:

Phone No:

Gender:

Can we leave a voicemail:

Email Address:

Agree to Email You:

Street Address:

City:

Post Code:

Date Of Birth:

Health Card No:

Version Code:

Preferred Pharmacy:

Previous Family Doctor Name:

Allergies:

Pertinent Medical History:

Current Medications:






SIGNATURE HERE : _______________________________________ | THE DATE : ______________

The patient-physician relationship is central to the role of the family doctor

Our Doctors use an evidence-based approach to recognize, diagnose and manage any medical illness. We provide continuing and comprehensive care, periodic health maintenance, and preventive services to each member of the family, regardless of gender or age. Additionally, if a health condition arises that requires care from another specialist, your Physician will be there to guide you and to coordinate all aspects of your care.


Family Doctors Accepting New Patients!
Our Family Doctors:
FAMILY DOCTOR

Peventive Medicine

Let’s start the discussion today about how to keep you healthy! Our doctors offer preventative medicine to our patients: ColonCaner Screening, Breast and Cervical Cancer Screening, Bone Density Tests, Health Lifestyle Changes, Immunizations and .. etc

Chronic Illness Management

Family Doctors are trained to diagnose and manage many common chronic illnesses like: Diabetes, Hypertension, Mental Illnesses, Thyroid diseases, Asthma. etc. Also will facilitate and coordinate specialists referral if needed.

Continuity of Care

Our Doctors will navigate the health care system with patients, including specialist and hospital care coordination and follow-up, to deliver a connected and coordinated care to the patients while moving between providers and through the healthcare system.

* Completion of New patient application form does not guarantee registration at our clinic. Once the completed form has been submitted and reviewed, our front desk staff will contact you to arrange for a Meet & Greet appointment. Please be truthful and complete the application in its entirely. Failure to do so will delay the processing of your application.