Patient Enrollment Request

First Name*

Middle Name

Last Name*

Email Address*

Phone Number*

Date of Birth*

Gender*

Health Card Number*

Version Code*

Health Card Expiry*

Street Address*

Unit

City*

Postal Code*

Province*

Please list any allergies you may have or leave as "NKDA" if you do not have any known allergies:*

Please list any relevant medical history or existing medical conditions or leave as "healthy" if you do not have any known conditions:*

Please list any relevant surgical or hospitalization history or leave as "Never" if you've never been surgically treated / hospitalized*

Please list any medications you are taking or leave as "None" if you are not on any medications*

Select Clinic / Healthcare Provider*

All personal and health information is kept confidential and secure in accordance with applicable laws. MedCare Clinics operates under a shared care model. Completion of this form does not confirm a doctor-patient relationship. MedCare Clinics will not disclose any personal or health information to any third party (without express prior consent) except to those individuals necessary for the provision of medical services in accordance with applicable law. For all medical/physician services, a valid OHIP card must be presented at each visit to receive medical care. In the event an expired or invalid OHIP card is presented, patients will be billed directly for the medical appointment before the appointment. This payment is non-refundable. For all medical services not covered by OHIP, payment is required at the time of service. Some payments are non-refundable and may be subject to a processing fee. MedCare Clinics provides all patients with the required receipts and documents for submission to insurance companies or any 3rd party coverage providers. Please note that each patient's insurance agreement is an agreement between themselves and the insurance company directly. In the event that any insurance company or 3rd party coverage provider does not completely reimburse or reject any claim provided at MedCare Clinics, the patient remains responsible for all fees. Please note that certain healthcare providers at our facility exclusively see adult patients (18 years of age and older). We recommend verifying provider eligibility for younger patients prior to booking an appointment. Not all services are available and are subject to Provider availability. Please check with your local MedCare Clinics for further information. To ensure you receive the care you need, we recommend contacting your local MedCare Clinics directly. The clinic staff can provide you with up-to-date information about the services available at your specific location, as well as the availability of healthcare providers. Each individual patient is required to complete and submit a separate Patient Enrollment Request Form. Enrolling one family member does not automatically enroll other family members. Separate forms must be completed for each person seeking enrollment. By submitting this form, you acknowledge and understand the role of a physician assistant, clinical assistant, scribe and a nurse practitioner and consent to be seen and have healthcare services provided to me by a physician assistant, clinical assistant, scribe and a nurse practitioner working under the direct supervision and involvement of a licensed physician. I acknowledge that I have read and fully understand this form, disclaimers, terms of use, patient responsibilities and policies listed on the MedCare Clinics’ website. I consent to the conditions outlined herein, as well as any other instructions that the healthcare providers may impose to communicate with me as well as all of MedCare Clinic’s policies, terms and conditions. By signing this document, I agree to waive all claims (including but not limited to, medical malpractice) that I have or may have in the future against MedCare Clinics. I agree to release MedCare Clinics from all liability for any loss, death, damage or injury that my next of kin or I may suffer for any negligence, breach of contract, malpractice, or breach of any statutory or other duty of care. I also expressly consent and authorize MedCare Clinics to contact me via email or text messages for news and updates in regard to the clinic and its services and appointment reminders. All references to MedCare Clinics include its directors, officers, physicians, employees, agents and affiliates or other related companies (including any successor companies to MedCare Clinics).

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