New Patient Form

At McDermot Health Centre, our mission is to provide compassionate and comprehensive healthcare to our community, prioritizing patient well-being and fostering a culture of trust, respect, and collaboration.

Family Care Medicine

Preventive Medicine

Women's Health Care

Open For Walk-Ins

Same Day Appointments

Accepting New Patients

Travel Clinic & Immunization

General Practitioners

Family Care Medicine

Preventive Medicine

Women's Health Care

Open For Walk-Ins

Same Day Appointments

Accepting New Patients

Travel Clinic & Immunization

General Practitioners

Print PDF File

Please click on the button below to download a oneline filalble form or a printable PDF file.

New Patient Form

Your Information

Please fill out the form below and we will get back to you as soon as possible. Your information will be kept confidential.

First Name *

Last Name *

Cell Phone *

Home Phone

Email *

How Did You Hear About Us

Gender *

Do You Have a Family Doctor? *

Health Card PHIN (9 Digits) *

Health Card Reg # (6 Digits) *

Address *

City *

Province *

Postal Code *

Health Insurance

Date of Birth *

6 Digit Code *

Medications (Names Only) *

Family History *

Past History *

Message *

New Patient Form

Family Care Medicine

Preventive Medicine

Women's Health Care

Open For Walk-Ins

Same Day Appointments

Accepting New Patients

Travel Clinic & Immunization

General Practitioners

Family Care Medicine

Preventive Medicine

Women's Health Care

Open For Walk-Ins

Same Day Appointments

Accepting New Patients

Travel Clinic & Immunization

General Practitioners

Email

Phone

Fax

Print PDF File

Your Information

New Patient

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