Patient Registration
Credit Valley Wellness Centre (905) 820-9990
Primary Contact Information and Consent to Examination
Electronic Transmission Authorization & Consent (for Direct Billing Claims to Extended Health Benefits/Insurance)
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Email *
Consent to use Electronic Communications *
Our clinic can provide electronic communication from our doctors.  Please let us know the method(s) we may communicated with you. (For complete terms: http://creditvalleywellness.com/consent-to.html)
Yes
No
Email
Instant/Text Messaging (SMS, MMS)
Full Legal Name
LAST, First I.
Date of Birth *
MM
/
DD
/
YYYY
Address: *
Use the format: Apt#-Number and Street, eg. 209-2000 Credit Valley Road
City
Province *
Postal Code *
Use format eg. L5M 4N4
Telephone *
Include area code and number eg. 905-820-9990
Primary Care Physician (Family Doctor) Name or Clinic Name *
Primary Care Physician (Family Doctor) Telephone
Diagnosed Conditions (eg. Cancer, Cardiovascular, Metabolic, Joint Surgery etc...) *
Current Medications *
What is your Primary Health Concern for today's visit? *
Required
If Patient is <18yrs old, Parent/Legal Guardian Name
Would you like to use your Extended Health Benefits (Workplace Health Insurance) Direct Billing? *
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