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Dr. Andrew Smith Rostering Form

For your convenience and reference we summarized the steps of completing the forms included below: 

Page 1: Patient Enrolment and Consent to Release Personal Health Information:

Page 2: Primary Health Care New Patient Declaration:

Page 3: Patient Enrolment and Consent to Release Personal Health Information

Please return the completed form (pages 1 AND 2) to our office by e-mail at rostering@tworiversfht.ca or mail, at

Attention: Rostering

HealthLink Family Practice 

B10-350 Conestoga Blvd.

Cambridge, ON  N1R 7L7

If you are scanning the document and sending via e-mail we do not require the original form provided that the scan is clear and your signature is legible.

Lastly, while we have the email addresses of some of our patients, we do not have all.  Having your email address will allow us to communicate with you on a more timely basis.  If you have not yet provided us with your email address and would like to please CLICK ON THIS LINK to be redirected to our online form and click on "Existing Patient".

 

Thank you.

 

Yours truly,

 

Dr. Andrew Smith

Andrew Smith B.Arts Sc. (Hons), MD, CCFP

 

Attachment (click to download):
 Adobe Acrobat Document Dr Andew Smith Enrolment Form.pdf