DREAM KIDS CLINIC

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DREAM KIDS CLINIC

NEW PATIENT REGISTRATION

Email *

Patient Name *

First - Middle - Last

Date of Birth *

Month / Day / Year

Gender *

Male

Female

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? *

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? *

Online reviews from Google Search / Google Maps.

Recommendation from someone I know.

Social media post.

Other

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