DREAM KIDS CLINIC
NEW PATIENT REGISTRATION
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Email *
Patient Name *
First - Middle - Last
Date of Birth *
Month / Day / Year
Gender *
Home Address *
Full Address (ex: 479 Dundas St. W, Oakville ON, L6M 1L9)
Primary Contact Number *
Please include dashes between numbers (ex: 905-286-1134)
Secondary Contact Number *
Please provide a secondary number in case we are unable to reach you for urgent matters, such as abnormal lab or imaging results.  

Please include dashes between numbers (ex: 905-286-1134)
Health Card Number *
10 digits + 2 letter code (ex: 9052863411-DK) 
Does Your Child Have an Existing Doctor?  *
How Did You Find Our Clinic? *
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