Crosstown Family Health Team - Patient Intake Form
Please provide your personal and contact information for our records.  

Privacy Notice: Information submitted through this form is not sent through a secure system. If you prefer not to share personal or health information online, please contact our office by phone at 416-242-2850 x6 between 8:00 AM - 4:00 PM any day of the week.
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First Name *
Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Health Card Number  *
Health card number and version code are needed to confirm the card is valid before attending the appointment.
Health Card Version Code (2 letters) *
Health card number and version code are needed to confirm the card is valid before attending the appointment.
Street Address *
City
Province
Postal Code
Phone Number *
Email Address *
How did you hear about us?
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