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New Patient Form

First Name

Last Name

Date of birth

Gender

Male

Female

Other

Address

Address Line 1

Address Line 2

City

Province

Postal Code

Country

Home Phone #

Cell Phone #

Work Phone #

Preferred Contact

Home

Cell

Work

Health Card Number (OHIP). (0000-000-000-XX)

If you have a refugee status, add the UCI number

Upload a copy of IFH paper

Choose File

If you don’t have any insurance, upload your passport copy

Choose File

Name of your preferred doctor

Emergency Contact Name:

Relationship to you:

Emergency Contact Phone #

Allergies:

Medications:

Consent

I have read and accepted Mi Clinic’s terms and conditions