Dr. Nicole Carpe New Patient 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:

• To enroll yourself:  complete sections 1 and 3
• To enroll 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 enroll 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.
• Note that page 2 is also required, as “new patient” means new patient of Dr. Carpe.

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 need to be completed and signed) to our office by clicking here or emailing* rostering@tworiversfht.ca or by mail, at

Attention: Rostering
HealthLink Family Practice
B10-350 Conestoga Blvd.
Cambridge, ON  N1R 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.

*note that emailing your completed roster forms is not a secure form of communication.

Thank you.

Attachment (click to download):

Dr. Carpe Roster Form