New patient registration

Your spot is reserved — you have --:-- left to submit this form.

Eligibility Requirement

Notice - We only accept patients who reside in the City of Clarence-Rockland (Rockland, Bourget, Cheney, Clarence, Clarence Creek, Hammond, St-Pascal-Baylon) and Wendover.

Demographic Information

Surname *

First name *

Middle name (if applicable)

Preferred name (if applicable)

Birthdate (YYY-MM-DD) *

Sex *

Title (Mr., Ms., Dr., etc.) (optional)

Pronouns (if applicable)

Contact Information

Address *

Apartment

City *

Province

Ontario

Postal code *

Email *

At least one phone number is required *

Home Phone Number

Work Phone Number

Mobile Phone Number

Health Card & Pharmacy Information

Health Card Number *

Version Code *

Expiry Date *

Preferred Pharmacy *

Preferred Language *

Proof of Residence (Required)

Upload a recent proof of residence (less than 3 months old)
(e.g. utility, internet bill, property taxes). Photos of driver’s licences will NOT be accepted.
For children, please use the same proof of residence as yours.
Accepted Formats = PDF, JPG, PNG.

New patient registration

Eligibility Requirement

Demographic Information

Contact Information

Health Card & Pharmacy Information

Proof of Residence (Required)

Consent & Privacy

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