STONEGATE CHC
New Client Registration Form

Personal Information

CONFIDENTIAL

If you have any questions or would like to speak to someone about
completing this form, contact us at 416.231.7070 ext. 307

For data collection purposes we ask that you do not leave any question unanswered. If you prefer not to answer a question, select the option (where ever it is available) : prefer not to answer.

We are currently accepting registrations for our Primary Health Care waiting list.

You are eligible if you:
Do not currently have a family doctor
Live within our catchment area, including the following postal codes:
M9A ,M8X ,M9B
M8Y & M8Z north of The Queensway only

*Contact Information:(Required.)

First Name:

Last Name:

Address

City

Province

Postal Code

Date of Birth

I have no fixed address

Yes

*Preferred Contact:(Required.)

Home Phone:

Work Phone:

Cell Phone:

Email:

*Email address:(Required.)

I consent to Stonegate CHC sending me electronic communications including newsletters about programs and services and center wide updates.

*May we leave a voicemail on the main contact number?:(Required.)

Yes

Emergency Contact:

Name:

Phone:

Relationship:

OHIP information

Health Card Number

Version Code

Expiry Date

Medical condition or restrictions:

Yes

Allergies(please specify):

Please Specify:

*PROGRAMS AND SERVICES AVAILABLE:
Please check all programs you are interested in.

(Required.)

1. Asthma Education /Support

2. Children’s Programs (0-6yrs)

3. Chiropody (foot & leg care)

4. Counselling

5. Diabetes Education/support

6. Dietitian

7. Family Doctor/Nurse Practitioner

8.Pre and Postnatal Programs

9. Seniors Wellness

10. Settlement Services

11. Women’s Programs

12. Children After School Recreational Programs (6-12 yrs)

13. Fitness Program

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STONEGATE CHCNew Client Registration Form

STONEGATE CHC
New Client Registration Form