PATIENT REGISTRATION FORM Registration steps:Step 1: Complete this form to register.Step 2: If you need a family doctor, complete the “health history form” in addition to completing the “patient registration form”.Step 3: Book an appointment online or over the phone.Step 4: Within 24 hours prior to your clinic visit, complete the “COVID self-screening questionnaire”.Step 5: To complete your registration, visit the clinic with the following documents:i. A valid photo ID.ii. Alberta health card.Complete this form to register in the clinic. Appointments may be booked online or over the phone. Kindly review our Clinic Policy. PATIENT REGISTRATION FORM (New) Patient Registration: please fill out the form below: First NameMiddle NameLast NamePhoneEmailDate of BirthGender Female MaleMarital Status Single Married Separated Divorced Common lawHealth Card Number Is this an Alberta Health Card? Yes NoIf 'NO', which province?AddressCityProvincePostal CodeHome phone numberWork phone numberPrimary LanguageOccupationName of Emergency Contact PersonPhone number of Emergency Contact PersonRelationship with Emergency Contact PersonReason for visitPreferred pharmacyHow did you hear about us? Please check option(s) Door to door / direct flyers Community Magazine Google Facebook friend/family/acquaintance OthersOthers, please specify hereDo you have a preferred language other than English? Yes NoPreferred languageInvestigation Results Notification Notify me when my investigation results are available Do not Notify me of normal investigation results. I will return to the clinic for follow-upPatient’s signature Date / TimeSubmit Form