Book a Meet & Greet Appointment - ConnectCare Medical Clinic

Phone
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New Patient Pre-registration Form
Accepting Patients
- 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*
MM slash DD slash YYYY
Gender*
Home Address
Street Address City Province Postal Code
Your Family Information
Number of members in my family:*
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

Accepting new patients today!

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