Kanata Clinics Patient Waitlist Registration
Please complete this form to be added to the waitlist for new patients seeking a Family Physician at our practice.
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Email *
Date of Waitlist Submission *
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Full Legal Name *
Date of Birth (DD/MM/YYYY) *
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Health Care Number  *
Gender Identity *
Current Phone Number (Primary Contact) *
Email Address *
Current Residential Address (Street, City, Postal Code) *
Do you prefer a male or female clinician *
Required
Please select your preferred location in order of priority. Note that there is no guarantee you will be placed at your first choice; placement is strictly based on clinician capacity. Please be aware that almost all of our clinicians work out of a single location and do not travel between sites.
1st Choice (Ideal)
2nd Choice
3rd Choice
Coquitlam
Port Coquitlam
Maple Ridge
Clear selection
Do you currently have a Family Physician/General Practitioner? *
If you are seeking a new physician for other reasons, please briefly explain why: *
Are you registering any immediate family members (spouse, children) on this waitlist as well?
Clear selection
How did you hear about our practice?
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