Name First Name Last Name Date of Birth * MM DD YYYY Gender * Male Female OHIP Health Card Number & Version Code * Email * Home Phone Country (###) ### #### Cell Phone * Country (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country City * Address 1 Address 2 City State/Province Zip/Postal Code Country Province * Address 1 Address 2 City State/Province Zip/Postal Code Country Postal * Address 1 Address 2 City State/Province Zip/Postal Code Country Pre-existing medical conditions * Additional medical notes Any previous surgery? * Significant Family History * Current medications & dosage * Allergies * Immunizations Date of Application * MM DD YYYY Privacy and the Use of Internet & Email: * Internet communication is not 100% secure. While we strive to protect our patients by utilizing advanced patient messaging systems approved by the Ministry of Health and compliant with PIPEDA for patient privacy protection, we cannot guarantee the absolute security and confidentiality of any emails or messages you receive from us. Once the message leaves Openfield Medical Centre, it travels across the internet where it could potentially be intercepted and read. If you use a work email, please be aware that your employer may have the right to archive and inspect emails sent from their systems. It is advisable to avoid using a work email address. Openfield Medical Centre cannot be held responsible for any information loss resulting from technical failures. Email should never be used in cases of emergency. If you have an emergency, please call 9-1-1 or visit your nearest hospital emergency room or healthcare provider immediately. I acknowledge the risks associated with using email with Openfield Medical Centre, and I accept those risks. I affirm and certify that all the information provided and answers to the questions herein are complete, true, and correct to the best of my knowledge and belief. Thank you, your new patient enrolment was submitted.We’ll review your information and follow up by email within 2–3 business days. If you need care sooner, please visit a walk-in clinic, urgent care centre, call 811, or dial 911 in an emergency.
