As a new patient, your consent is required to enroll with the clinic for primary care services required by Ontario
Section 1 - Patient Commitment
- I will contact my family doctor first when I need primary care advice or treatment, unless there is an emergency or I am travelling.
- I will notify the clinic if I move and provide updated contact information.
- I understand I may de-enroll and enroll with another doctor after six weeks from signing this form (immediately if I have moved), and no more than twice per year.
- For enrolled children under 16: my signature confirms I agree to these terms on their behalf.
Section 2 - Consent to Release Personal Health Information
- I allow my doctor and the Ontario Ministry of Health to exchange enrollment information, name, address, and phone number.
- I allow the Ministry to release dates of immunizations, preventive care screenings (pap tests, mammograms), and service records from other providers.
- This consent ends when my enrollment ends or I cancel in writing to the Ministry.
Section 3 - Cancellation Conditions
- Enrollment ends if: I cancel, I no longer qualify under the Health Insurance Act, I enroll with another doctor, or the Patient Enrollment Model ends.
- Enrollment may end if I consistently fail to meet Patient Commitment obligations.