Book a Meet & Greet Appointment - ConnectCare Medical Clinic

New Patient Pre-registration Form

Accepting Patients

Male Doctor at Spruce Grove

Do you have a Alberta Health Card or other provincial health card number?*

Yes
No

Alberta Health Card Number*

Or, other provincial health card number

Confirm Province of Health Card Number*

Province

To register as a new patient, we are required for all patients to have an Alberta Health Card or other provincial health card number.

Your Information

Which location would you like to pre-register for?*

Spruce Grove, Edmonton

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Which location would you like to pre-register for? v2*

I am registering for:*

myself
my family

Your contact details

Your Name*

First Last

Email*

Enter Email Confirm Email

Phone*

Date of Birth

Gender*

Home Address

Street Address City Province Postal Code

Your Family Information

Number of members in my family:*

Family member names (optional)

This optional section is provided to help save you time from registering each member individually.

First Name	Last Name	Relation (spouse, child, etc.)	DOB	Gender	Phone Number	Health Card Number + Province

Doctor Preferences

I am interested in:*

Family Care
Children Care
Women's Health
Long Term Illness
Other

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Doctor Preference (optional)

Female
Male
No preference

How did you hear about us?*

Can we contact you?

Yes

URL

This field is for validation purposes and should be left unchanged.

Accepting new patients today!

New Patient Pre-registration

New Patient Pre-registration Form

Your Information

Your contact details

Your Family Information

Doctor Preferences