New Patients

Welcome to Supreme Medical Clinic

Supreme Medical Clinic is accepting new patients. Use the secure Patient Enrolment Form below to provide your registration and health information to the clinic.

Start Patient Enrolment Book an Appointment

Information to Have Ready

Before beginning the form, it may help to have:

  • Health card information
  • Contact details
  • Previous family-physician information
  • Preferred pharmacy details
  • Current medications
  • Allergy information
  • Relevant medical history
Secure Registration

Patient Enrolment Form

Please complete the following information as accurately as possible. Fields marked with an asterisk are required. Do not use this form for an emergency.

1
Personal
2
Previous Care
3
Medical History
4
Meds & Allergies
5
Consent

Step 1 of 5 — Personal Information

Patient Details

Health Card Information

If you cannot provide it, enter “N/A”.

Address

Contact Information

Step 2 of 5 — Previous Care

Step 3 of 5 — Medical History

Please select any conditions that apply.

Step 4 of 5 — Medications and Allergies

Current Medications

Allergies

Health and Substance Information

Step 5 of 5 — Consent and Declaration

Declaration: I confirm that the information provided in this form is accurate and complete to the best of my knowledge.

Collection, Use and Disclosure: I consent to the collection, use and disclosure of my information for healthcare, treatment, payment and clinic operations, as permitted by applicable requirements.

Appointment Communications: I consent to receiving appropriate appointment reminders or administrative communications by telephone, email or text message. I understand that I may withdraw communication consent by contacting the clinic, subject to applicable requirements.