New Patient Registration | Evergreen Family Health Centre

New Patient Intake form

Name *

Date of Birth *

Gender *

Male
Female

OHIP Health Card Number & Version Code *

Email *

Home Phone

Cell Phone *

Address *

City *

Province *

Postal *

Pre-existing medical conditions *

Additional medical notes

Any previous surgery? *

Significant Family History *

Current medications & dosage *

Allergies *

Immunizations

Date of Application *

Privacy and the Use of Internet & Email: *

Internet communication is not 100% secure. While we strive to protect our patients by utilizing advanced patient messaging systems approved by the Ministry of Health and compliant with PIPEDA for patient privacy protection, we cannot guarantee the absolute security and confidentiality of any emails or messages you receive from us. Once the message leaves Evergreen Family Health Centre, it travels across the internet where it could potentially be intercepted and read.
If you use a work email, please be aware that your employer may have the right to archive and inspect emails sent from their systems. It is advisable to avoid using a work email address.
Evergreen Family Health Centre cannot be held responsible for any information loss resulting from technical failures.
Email should never be used in cases of emergency. If you have an emergency, please call 9-1-1 or visit your nearest hospital emergency room or healthcare provider immediately.I acknowledge the risks associated with using email with Evergreen Family Health Centre, and I accept those risks.
I acknowledge the risks associated with using email with Evergreen Family Health Centre, and I accept those risks.
I affirm and certify that all the information provided and answers to the questions herein are complete, true, and correct to the best of my knowledge and belief.

Patient Acknowledgement

Evergreen Family Health Centre will contact you by email or phone to provide information regarding the following:

Appointment bookings and scheduling
Referral bookings
General information about our office and clinics
Test results
To ensure that you receive our emails, please remember to update your address book with our email address info@efhc.ca and check your junk/spam folder regularly.