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.

First Name*

Last Name*

Address*

City*

Province*

Postal Code*

Email Address

Phone*

Birthday*

Month Day Year

Month January February March April May June July August September October November December   Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917

Gender*

Choose in Drop Down Male Female

Name & Location of current Family Doctor

Or currently you do not have a Family Doctor

No I don't

My Preferred Service Location is

Wellington

Picton

I am willing to accept services in

Wellington

Picton

Name of person filling out this form (if different from applicant)

Relationship to Applicant

Alternate Telephone #

Best time to call*

Day

Evening

Enter the code displayed*