Patient Enrolment

Section 1:

I want to enroll myself with the family doctor identified in Section 4

My Last Name *

Last

My First Name *

First

My Second Name

Second Name

My Health Number

My Version Code

My Date of Birth

My Sex - Male

Male

My Sex - Female

Female

Send notices from my family doctor’s office to me by:

Notice by regular mail

regular mail

Notice by email

email (if possible)

My Email Address *

Enter Email

Confirm My Email Address *

Confirm Email

My Mailing Address

My Mailing Address Apartment #

My Mailing Address Street No. and Name or P.O. Box, Rural Route, General Delivery

My Address City/Town

My Address Postal Code

My Resident Address

My Residence Address (same)

same as mailing address

My Resident Address Apartment #

My Resident Address Street No. and Name or P.O. Box, Rural Route, General Delivery

My Resident City/Town

My Resident Postal Code

Section 2:

I want to enrol my child under 16 and/or dependent adult(s) with the family doctor identified in Section 4

Child 1

A (Child 1) ----------------------------------------------------

Child 1 Last Name *

Last

Child 1 First Name *

First

Child 1 Second Name

Second Name

Child 1 Health Number

Child 1 Version Code

Child 1 Date of Birth

Child 1 Sex Male

Male

Child 1 Sex Female

Female

I am child 1's parent

parent

I am child 1's guardian

guardian

I am child 1's attorney for personal care

attorney for personal care

Child 1 Mailing Address (same as 1)

Same as Section 1

Child 1's Mailing Address Apartment #

Child 1's Mailing Address Street No. and Name or P.O. Box, Rural Route, General Delivery

Child 1's Mailing Address City/Town

Child 1's Mailing Address Postal Code

Child 1 Resident Address (same as 1)

Same as Section 1

Child 1's Resident Address Apartment #

Child 1's Resident Address Street No. and Name or P.O. Box, Rural Route, General Delivery

Child 1's Resident City/Town

Child 1's Resident Postal Code

I want to enrol a second child under 16 and/or dependent adult(s) with the family doctor identified in Section 4

Child 2

B (Child 2) ----------------------------------------------------

Child 2 Last Name *

Last

Child 2 First Name *

First

Child 2 Second Name

Second Name

Child 2 Health Number

Child 2 Version Code

Child 2 Date of Birth

Child 2 sex male

male

Child 2 sex female

female

I am Child 2's parent

parent

I am Child 2's guardian

guardian

I am Child 2's attorney for personal care

attorney for personal care

Child 2 Mailing Address (same as 2)

Same as Section 1

Child 2's Mailing Address Apartment #

Child 2's Mailing Address Street No. and Name or P.O. Box, Rural Route, General Delivery

Child 2's Mailing City/Town

Child 2's Mailing Postal Code

Child 2 Resident Address (same as 2)

Same as Section 1

Child 2's Resident Address Apartment #

Child 2's Resident Address Street No. and Name or P.O. Box, Rural Route, General Delivery

Child 2's Resident City/Town

Child 2's Resident Postal Code

Section 3 Signature

I have read and agree to the Patient Commitment, the Consent to Release Personal Health Information and the Cancellation Conditions at the bottom of this form. I acknowledge that this Enrolment is not intended to be a legally binding contract and is not intended to give rise to any new legal obligations between my family doctor and me.

I am signing on behalf of (check all that apply)

Signing for myself

myself

Signing for my child(ren)

child(ren)

Signing for dependent adults

dependent adults

My last name & My first name

My Signature

Clear

Date My Form Signed

My Home Phone

My Work Phone

Section 4 - Family Doctor Information

PG00898
DR. PRESTON ZULIANI
THOROLD FAMILY HEALTH CENTRE FHO
1 BELTON BLVD
ST CATHARINES, ON L2T3Y4
BILLING NO. 189258 GROUP NO. BAYQ

Family Doctor's Signature

Clear

Doctor's Signature Date Signed

Patient Enrolment and Consent to Release Personal Health Information

Patient Commitment
I agree to contact my family doctor, (or if applicable the group to which my family doctor belongs or the designated Telephone Health Advisory Service if available to me), when I, or my enrolled child(ren) or dependent adult(s), need primary care medical advice or treatment. I promise to do this unless there is an emergency or I am travelling away from home.

I agree that if I or the person(s) I have signed for move, I will contact my family doctor's office or the ministry (see box below) with a new address and telephone number.

I understand that I can end my enrolment with this family doctor and enrol with another family doctor after six weeks have passed from the date that I complete and sign this form (immediately if I have moved). However, I agree not to change the doctor with whom I am enrolled more than twice a year.

I understand that by enrolling a child under 16 or a dependent adult, my signature on the front of this form means that I agree to these terms and conditions on behalf of that person. When an enrolled child reaches 16 years of age, the ministry will contact him or her to confirm enrolment/consent with the family doctor.

Consent to Release Personal Health Information
I understand that my family doctor will be able to offer better medical care if I permit my family doctor and the ministry to share appropriate and relevant information relating to my health.

I agree to allow my family doctor, other family doctors in the Patient Enrolment Model (if applicable) and the ministry to exchange the information in this form related to my enrolment.

I agree that my family doctor and the ministry can exchange information about my name, address and telephone number.

I agree to allow the ministry to release the following specific information to my family doctor:
• dates of immunizations (flu shots, etc.)
• dates of preventive care screening services (pap tests, mammograms, etc.)
• dates of service, fees paid and fee codes of primary health care services provided to me by a family doctor outside my family doctor's Patient Enrolment Model (if applicable).
If the Telephone Health Advisory Service is available to me, I agree to allow my family doctor and the ministry to exchange only the following information with the designated Telephone Health Advisory Service: my name, health number and version code, address, date of birth, gender.

I understand that this consent to release personal health information ends when:
• My enrolment with my family doctor ends or
• I cancel my consent by writing or telephoning the Ministry of Health and Long-Term Care (see box below).
The ministry will inform my family doctor when the consent is no longer valid. However, I understand that the information already released to my family doctor will remain in my medical file.

Cancellation Conditions
Enrolment with my family doctor and my consent to release personal health information will end when:
a) I cancel my enrolment by writing my family doctor or by writing or telephoning the ministry (see box below);
b) I no longer qualify for health care services under the Health Insurance Act (Ontario);
c) the Patient Enrolment Model to which my doctor belongs no longer exists;
d) my family doctor chooses to discontinue acting as my family doctor in accordance with the College of Physicians and Surgeons of Ontario guidelines;
e) I enrol with another family doctor; or
f) the ministry grants me an extended absence.

My enrolment with my family doctor and my consent to release personal health information may end when:
a) I consistently fail to meet the obligations to which I agreed in the Patient Commitment (above);
b) my family doctor leaves this Patient Enrolment Model;
c) become a resident of a long-term care facility;
d) I am imprisoned in a provincial or federal correctional institution; or
e) I move outside the geographic area where the Patient Enrolment Model to which my family doctor belongs regularly provides services.

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Section 1:

I want to enroll myself with the family doctor identified in Section 4

Section 2:

A (Child 1) ----------------------------------------------------

B (Child 2) ----------------------------------------------------

Section 3 Signature

Section 4 - Family Doctor Information

Patient Enrolment and Consent to Release Personal Health Information

Contact Information:
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Section 1:

I want to enroll myself with the family doctor identified in Section 4

Section 2:

A (Child 1) ----------------------------------------------------

B (Child 2) ----------------------------------------------------

Section 3 Signature

Section 4 - Family Doctor Information

Patient Enrolment and Consent to Release Personal Health Information

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Contact Information:
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