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DREAM KIDS CLINIC
NEW PATIENT REGISTRATION
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Email
*
Your email
Patient Name
*
First - Middle - Last
Your answer
Date of Birth
*
Month / Day / Year
Your answer
Gender
*
Male
Female
Home Address
*
Full Address (ex: 479 Dundas St. W, Oakville ON, L6M 1L9)
Your answer
Primary Contact Number
*
Please include dashes between numbers (ex: 905-286-1134)
Your answer
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)
Your answer
Health Card Number
*
10 digits + 2 letter code (ex: 9052863411-DK)
Your answer
Does Your Child Have an Existing Doctor?
*
My child has a family medicine doctor or pediatrician for routine check-ups and vaccines.
My child is a newborn and has no primary care doctor.
We recently moved to Ontario, and have no primary care doctor for our child.
How Did You Find Our Clinic?
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Online reviews from Google Search / Google Maps.
Recommendation from someone I know.
Social media post.
Other
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