Register for a Family Doctor – Queen Medical Centre

Please fill in the form below

Patient Consent for Transfer/Registration as a Family Patient

I, the undersigned, consent to transfer/register with Dr. A. Hussain or Dr. Y. Hashmi (Please make a selection below) as a family patient and to transfer my record / profile from my current Family Physician .

Please select a doctor:

Dr. A. Hussain

Dr. Y. Hashmi

Patient's First Name

Patient's Last Name

Date of Birth

Health Card Number (OHIP)

Address

Address Line 1

Address Line 2

City/Postal Code

Phone Number

Preferred Contact Method

Phone

Mail

Emergency Contact Name

Relationship to Patient

Emergency Contact Phone Number

Medical Information

Please provide detailed medical information for the patient.

Family Physician (if transferring):

Current Clinic:

Pharmacy Name & Location:*

Current Medications

Allergies (Drugs/Food/Latex)

Past Surgeries

Medical Conditions

Consent to Collect, Use, and Disclose Health Information

I understand that my family doctor and clinic staff will collect, use, and disclose my personal health information in accordance with the Personal Health Information Protection Act (PHIPA), 2004, for the purposes of: Providing health care and treatment , Communicating with other healthcare providers, Processing payments and insurance claims, Administrative and quality assurance purposes

I consent to the collection, use, and disclosure of my health information for these purposes.

I understand that I may withdraw my consent at any time by notifying the clinic in writing.

For Clinic Use Only:

Patient Registered by:

Entered in EMR?

Yes

Chart #:

Date:

Monday	9:00 am – 6:00 pm
Tuesday	9:00 am – 6:00 pm
Wednesday	9:00 am – 6:00 pm
Thursday	9:00 am – 6:00 pm
Friday	9:00 am – 6:00 pm
Saturday	Temporarily OFF
Sunday	Closed