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Home
Team
Services
Insured vs. Non-insured
Blog
Policies
FAQ’s
Contact
Home
Team
Services
Insured vs. Non-insured
Blog
Policies
FAQ’s
Contact
Home
Team
Services
Insured vs. Non-insured
Blog
Policies
FAQ’s
Contact
New Patient Registration
Make an Appointment
New Patient Registration
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New Patient Registration Form
Please complete the fields below to submit your request to become a New Patient
First Name
Middle Name
Last Name
Manitoba Health Card Number (6 digits or characters)
Personal Health Identification Number (9 digits)
Where do I find my Health Card Number and Personal Health Identification Number?
Date of Birth (YYYY-MM-DD)
Gender
Female
Male
Other
Email Address
Primary Phone Number
Secondary Phone Number
Address 1
Address 2
City
Province
Postal Code
Emergency Contact Person
Emergency Contact Phone Number
Family Medical History
Medications
Allergies
Hospital Admissions
Other Information
Do you currently have a Family Doctor?
Yes
No
If yes, please provide Doctor Name and Clinic Address
If yes, why do you wish to change Doctors?
Physician Preference (We will try to accommodate patient preferences but cannot always guarantee which physician you'll be seen by)
Male
Female
No preference
How did you hear about us?
Former Patient
Radio Ad / Interview
Signs / Advertisements
Google
Facebook
Friend or Family
Family Doctor Finder
Other
If Other, please let us know how you heard about us:
Submit New Patient Registration
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Please note:
We will try to accommodate patient preferences, but we cannot always guarantee which physician you’ll be seen by.
Dr. Wilson’s waitlist is now closed.
Dr. Ajayi’s waitlist is now closed.
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