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Waitlist Form

Please note that if you have completed a paper waitlist form you don't need to complete an electronic one, and vice versa. Paper and electronic submissions are handled in the same way.
Waiting List Patient Information
First Name
Last Name
Date of Birth
Gender
Female  Male  Other / Prefer not to disclose  
Address
City
Postal Code
Home Phone #
Work Phone #
Mobile Phone #
Email
Have you been a patient of East Wellington Family Health Team in the past?
Yes No
Name of current physician (if any)
Current physician city
Do you have any significant health concerns?
Clinic Preference
Erin  Rockwood  Either/First Available  
Physician Preference
Male  Female  Either/First Available