Submit Your Details

First Name as per HEALTH CARD or ID *

Last Name as per HEALTH CARD or ID *

Gender *

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:

Applewood Medical 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:
1. Internet communication is not 100% secure.
2. I agree that Applewood Medical 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 Applewood Medical 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*

Walk-in Appointment Request