Book a Meet & Greet Appointment - ConnectCare Medical Clinic

New Patient Pre-registration Form

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

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.

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

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

I am registering for:*

Your Name*

First Last

Email*

Enter Email Confirm Email

Phone*

Date of Birth

Gender*

Home Address

Street Address City Province Postal Code

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

I am interested in:*

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Doctor Preference (optional)

How did you hear about us?*

Can we contact you?

Phone

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