Family Physician Request Submit Your Details First Name as per HEALTH CARD or ID Last Name as per HEALTH CARD or ID * Gender Male Female Age (In Years/Months) Street # and Street Address Unit# (if applicable) City Postal Code Email-ID Cell Phone Home Phone Please list Medical Conditions if you have any Please list Medications You take Please list Allergies if you have any Lifestyle Tobacco Use Alcohol Use Other Drug Use (Current or Past) Not Applicable Patient Acknowledgment Eastern Clinic will contact you by email or phone to inform you about: Appointment bookings and reminders, Referral bookings, General information about our office and clinics, Test results Privacy and using internet & Email: a. Internet communication is not 100% secure. b. I agree that Eastern Clinic shall not be responsible for any personal injury including death, and/or privacy breach or other damages as a result of my choice to receive emails and I release the Eastern Clinic from any liability relating to communicating with me by email. I acknowledge the existence of a waiting list, and understand that submitting this request for family practice intake does not ensure acceptance. Physicians accepting new patients will review applications in the order they were received. I will be contacted once I have been accepted, though the exact timing remains uncertain as availability depends on when spots open up. I acknowledge all above Digital Signature* Submit
