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New Patient WAITLIST Intake Form
Failure to complete intake forms in full will results in further delays in your form being processed
Please note:
  1. Completion and submission of our intake form does NOT guarantee that you will be accepted as a patient at Marine Gateway Medical Clinic. This is a WAITLIST for future doctors joining our practice
  2. Patients who are accepted are placed on a waiting list and are only contacted for an appointment when physician availability permits

IF YOU HAVE A MEDICAL EMERGENCY PLEASE VISIT YOUR LOCAL EMERGENCY DEPARTMENT.

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Full Name  on Care Card/BC Services Card (Legal) *
Preferred Name (Alias)
Care Card/BC Services Card/MSP Number (Do not add spaces between the numbers. Should start with a 9)
 *
Date of Birth
 *
MM
/
DD
/
YYYY
Sex
 *
Marital Status
 *
Home Address
 Street Number and Name, City AND Postal Code -- ex. 1234 Bird St, Richmond, BC, V7S 1Y8
 Street Number and Name ex. 1234 Bird Street
 *
City ex. Richmond
 *
Postal Code ex.  V7S 1Y8
 *
Cell Phone Number
 *
Home Phone Number
Work Phone Number
Email Address
Do you consent to electronic communications through the portal (secure emailing system) and/or email if needed?
 *
Emergency Contact (Name, Phone Number, AND Relationship to you -- ex. Jane Daniel, 604-123-4567, Mother)
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