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New Patient Form

This form is necessary to fill out accurately so as to get a complete and detailed record of you as a patient
(please do not miss any fields).

***All of your information is kept strictly confidential.***

Vaughan Medical Centre, 9200 Weston Rd, Woodbridge, ON, L4H 2P8 (905) 417-2273 (CARE)

*Preferred Appointment Time:
Preferred Appointment Date:	/ / (mm/dd/yy)

First Name:		Last Name:
Address:		City:
Country:		Postal Code:
E-mail:
Home Phone:		Work Phone:
Date of Birth:	/ / (mm/dd/yy)
Age:		Gender:	Male Female
Marital Status:		Children if Any:
Referred By:
Occupation:

Emergency contact and Family Dr info:
First Name:
Last Name:
This person's relation to you:
Phone number where they can be reached:
Your doctor's name:
Doctor's Phone Number:
Doctor's Fax Number:

For fee guide please see Fee Schedule

*Please note that all cancelling or rescheduling of appointments must be done 72 hrs (3 business days) prior to the scheduled appointment. Otherwise a full appointment charge cancellation fee will be applied to your credit card.

We appreciate your compliance with all scheduled appointments.

"I agree that all the above information is true, and that by checking this box,
I agree to the terms and conditions outlined above."

I Agree.

Vaughan Medical Centre 2009-2010