Patient Registration Form

1 Acknowledgement

2 Personal Information

3 Medical History

Before your telemedicine appointment, we would like to inform you:
- A telemedicine appointment is just like a regular doctor’s appointment; except the physician you will see and speak with is on a monitor;
- A trained healthcare provider will assist you during your telemedicine appointment; he/she will make the connection with the physician at another location;
- You may withdraw consent to the telemedicine appointment at any time without affecting your right to future care or treatment;
- A telemedicine appointment with a healthcare provider is available to anyone with a valid Ontario Health Card;
- This is a service covered by OHIP. If you are not a resident of Ontario, the fee for service is $120 but may be eligible for inter-province compensation with exception for Quebec.
Protecting your personal health information is important to us. All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Your telemedicine appointment is private and confidential, and it is only seen and heard by the health care provider involved. For more information please visit our website at www.otn.ca or contact the Privacy Officer at privacy@otn.ca. It is our clinic policy that no narcotic or controlled substances will be prescribed during walk-in appointments. The same applies to the telemedicine appointments. Please note that NOT ALL conditions can be looked after through telemedicine. You understand that you have the option to seek care at other clinics. I have read and acknowledged the above:
Which IDA Walk In Clinic would you prefer to visit?*
Confirmation
- I have read and acknowledged the above

Name*
First Middle Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender*
Email
Family Doctor*
- Yes
- No
Physician's Name
Do you have an OHIP Number*
- Yes
- No
OHIP Number
Version Code
Expiry Date
Date Format: MM slash DD slash YYYY
Which pharmacy do you currently have your prescriptions filled?*
Address*
Street Address Apt # City Province Postal Code
Preferred Daytime Phone*
Home Phone
Work Phone
Cell Phone
Emergency Contact
First Last
Emergency Contact Relationship
Emergency Contact Phone

Patient Registration Form

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