STONEGATE CHC
New Client Registration Form

Personal Information

CONFIDENTIAL

If you have any questions or would like to speak to someone about
completing this form, contact us at 416.231.7070 ext. 307

For data collection purposes we ask that you do not leave any question unanswered. If you prefer not to answer a question, select the option (where ever it is available) : prefer not to answer.

Stonegate CHC waitlist for Primary Health Care is currently closed.
If you are non-insured and non-status please contact the clinic directly.

Question Title

* Contact Information:

First Name:

Last Name:

Address

City

Province

Postal Code

Date of Birth

Question Title

* I have no fixed address

Yes

Question Title

* Preferred Contact:

Home Phone:

Work Phone:

Cell Phone:

Email:

Question Title

* Email address:

I consent to Stonegate CHC sending me electronic communications including newsletters about programs and services and center wide updates.

Question Title

* May we leave a voicemail on the main contact number?:

Yes

Question Title

* Emergency Contact:

Name:

Phone:

Relationship:

Question Title

* OHIP information

Health Card Number

Version Code

Expiry Date

Question Title

* Medical condition or restrictions:


Yes	Yes
No	No
Allergies(please specify):	Allergies(please specify):

Please Specify:

Question Title

* PROGRAMS AND SERVICES AVAILABLE:
Please check all programs you are interested in.
NOTE: Our Primary Health Care waitlist is currently closed.

1. Asthma Education /Support

2. Children’s Programs (0-6yrs)

3. Chiropody (foot & leg care)

4. Counselling

5. Diabetes Education/support

6. Dietitian

7.Pre and Postnatal Programs

8. Seniors Wellness

9. Settlement Services

10. Women’s Programs

11. Children After School Recreational Programs (6-12 yrs)

12.Sexual Health Clinic

STONEGATE CHCNew Client Registration Form

Question Title

* Contact Information:

Question Title

* I have no fixed address

Question Title

* Preferred Contact:

Question Title

* Email address:

Question Title

* May we leave a voicemail on the main contact number?:

Question Title

* Emergency Contact:

Question Title

* OHIP information

Question Title

* Medical condition or restrictions:

Question Title

* PROGRAMS AND SERVICES AVAILABLE: Please check all programs you are interested in. NOTE: Our Primary Health Care waitlist is currently closed.

STONEGATE CHC
New Client Registration Form

* PROGRAMS AND SERVICES AVAILABLE:
Please check all programs you are interested in.
NOTE: Our Primary Health Care waitlist is currently closed.