The below is only for patients who have been contacted by our office. Do not proceed if you have not been asked to complete a roster form by our office.
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:
To enrol yourself: complete sections 1 and 3
To enrol yourself and up to two children under 16 years of age and/or dependent adults for whom you are a parent, legal guardian or attorney for personal care: complete sections 1, 2 and 3
To enrol children under 16 years of age and/or dependent adults for whom you are a parent, legal guardian or attorney for personal care but not yourself: complete sections 2 and 3. (If more than two children under 16 years of age, you may print off another set of forms to fit these additional children)
Page 2: Primary Health Care New Patient Declaration:
Please complete the following: patient declaration, sections A, B (if applicable) and C.
Page 3: Patient Enrolment and Consent to Release Personal Health Information
This page is for you to review for your information. No need to print this page.
Please return the completed form (pages 1 AND 2) to our office by clicking here or mail, at
Attention: Forms Hespeler Medical Clinic B12-350 Conestoga Blvd. Cambridge, ONN1R 7L7
If you are uploading a digital copy of the completed roster form we do not require the original form provided that the scan is clear and your signature is legible.
Lastly, if you have not yet had an appointment with me I would like you to please CLICK ON THIS LINK and then click on “New Patient” to complete the secure, online new patient form to help me prepare for our first visit.