Patient Intake

Register as a New Patient

Name: Oak Ridges Medical and Urgent Care Centre
Address: 13291 Yonge Street, Suite 100, Richmond Hill, ON, L4E 4L6
Telephone: (905) 773-7759

Complete the patient intake form below so our team can better understand your health needs before your visit.

Please fill out the following form to help us understand your physical condition.

Patient Information

First Name

Last Name

Email Address

Phone

Gender / Sex

Date of Birth *

Health Card #

Health Card Version Code

Address

City

Province

Postal Code

Emergency Contact

Emergency Contact 1

Name

Relationship

Phone

Emergency Contact 2

Name

Relationship

Phone

Health History & Concern

(symptoms, diagnosis, duration, onset)

Health Concern

Allergies

When Did It Start?

Are you currently suffering from a medical condition, illness, or injury? *

No Yes

Have you been hospitalized in the last 12 months? *

No Yes

If you answered yes to any question, please elaborate

Medications

Initials

Today's Date

I declare that the information I've provided is accurate & complete.

Your Information Is Kept Private

All information submitted through this form is handled in accordance with our clinic policies and applicable privacy legislation. If you have questions before registering, please don't hesitate to call us.

View Our Policies Call Us: (905) 773-7759