Patient Enrollment Application

If you prefer to fill out a paper form, download it below

Introduction

The Prince Edward Family Health Team accepts new patients as openings become available within individual doctors' practices. Your completed application will be added to the waitlist and you will be contacted when an opening is available.

Instructions

  • Please fill out one application for each individual applicant.
  • In the case of an application filled out on behalf of another person please fill in the name and the relationship of the applicant to the person filling out the form. Missing or inaccurate information may result in delay of processing this application.
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Birthday*
  
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Or currently you do not have a Family Doctor
My Preferred Service Location is
I am willing to accept services in
Best time to call*
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Validation Code

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