Patient Registration
Sign in to Google to save your progress. Learn more
Last name as it appears on your BC Services Card: *
e.g. Simpson
Given name(s) as they appear on your BC Services Card *
e.g. Homer Jay
Preferred Name (optional):
Phone: *
Email: *
Postal Code: *
Birth Year *
Birth Month *
Day of Birth *
Personal Health Number (PHN):
Listed on your CareCard or the back of your BC Services Card.
Sex as listed on your BC Services Card: *
Gender information and preferred pronoun (optional):
Family Doctor (if applicable):
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy