New Patient Form

Complete your patient information before your visit so our clinic team can review your details and guide you through the next steps.

Before You Begin

This form is for new patients who would like to share their information with Dr. O. O. Oduntan's clinic at Dominion FHO, Grand Marais Medical Building. Please provide accurate details so the clinic team can review your information.

Form Review Required

Submitting this form does not automatically confirm an appointment.

Accurate Information

Please enter accurate patient and contact details.

Not for Emergencies

For urgent concerns, call emergency services or visit the nearest ER.

Patient Registration Form

Please complete the required fields below. Required fields are marked with an asterisk.

Personal Information

First Name *

Middle Name

Last Name *

Date of Birth *

Gender

Health Card Number *

Version Code *

Expiry Date *

Contact Information

Home Phone *

Cell Phone *

Email Address *

Postal Code *

Address *

City *

Province *

Current Doctor & Medication

Past / Current Doctor *

Current Medication *

Are you currently enrolled with another family doctor?

YesNoNot sure

Lifestyle & Medical Information

Tobacco Use Per Week *

Alcohol Use Per Week *

Narcotic Use in Past 2 Years *

Exercise / Physical Activity *

Allergies *

Surgeries *

Agreement & Signature

I certify that the information provided is accurate and complete. I understand that submitting this form does not confirm an appointment and that clinic policies must be followed. *

Date *

Signature *

By submitting, you confirm your details are correct.

AFTER SUBMISSION

What Happens Next?

STEP 1

Form Review

The clinic team reviews your submitted patient information.

STEP 2

Follow-Up if Needed

The clinic may contact you for additional details or next steps.

STEP 3

Patient Guidance

You will be guided based on the clinic's process and availability.

Questions About the Form?

If you need help with the new patient process, contact the clinic during office hours.

Email the Clinic View Office Hours