Request for a Family Doctor or Nurse Practitioner

 

Complete this form if you do not have a family doctor or nurse practitioner or if your doctor or nurse practitioner is not close by. Please fill out one form for each family member.

For more information on the process to become a patient please click here.

You can fill out our online form below or download and drop off or mail/fax a paper form if you prefer. Download the SEGCHC Request for a Family Doctor or Nurse Practioner form here.

Mail or Drop off to: South East Grey Community Health Centre PO Box 360, 55 Victoria Avenue, Markdale ON N0C 1H0

Fax: 519‐986‐3999

Please fill out one form for each family member.

Fields marked with an asterisk (*) must be filled out.

Name* :

Date of Birth:*

Address:*

Healthcard Number:*

Phone Number:*

Male or Female:* Male Female

Who was your last doctor or nurse practioner and when did you last see him/her?*

Reason for appointment/special needs (please check all that apply):*

Diabetes Management COPD Heart Disease Kidney Disease Addictions

Dementia/Alzheimer's Mental Illness Organ Transplant High Blood Pressure

Cancer / Receiving Treatment High Cholesterol Pregnancy Thyroid Condition

Taking Coumadin

Disabled Reason:

None Apply

Other:

List of Medications that you are currently taking: * If none, enter None

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