imgAll Clinics and Virtual Care Services will be closed Friday, March 29th and resume regular hours March 30th, 2024.

MD Connected Family Health Registration

PATIENT INFORMATION

CHILD(REN) UNDER 18 AND DEPENDENT(S)

Are you enrolling yourself only or at least one child or dependant? *

Up to 10

CHILD(REN) UNDER 18 / DEPENDENT(S)

Child’s or dependant’s residence and mailing address are the same as mine: *

I am this persons: *

SIGNATURE

I am signing on behalf of: *

Please type your signature: *

imgVirtual care services are open 8 am to 8 pm on weekdays and 9 am to 5 pm on weekends.