Walk-in Appointment 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 Reason to see Doctor 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
