Patient Intake at North York (Opening Soon)

North York - Opening Soon!

262 Marlee Ave, North York, ON M6B 3H7

Be first in line when we open. Complete this one-page patient intake form and our care team will reach out with next steps and early access to booking.

Patient Intake Form

Everything we need to welcome you, all on one page. Fields marked * are required.

Personal Information

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth *

Gender *

Home Address

Address *

City *

Province *

Postal Code *

Emergency Contact

Emergency Contact Name *

Emergency Contact Phone *

Relationship *

Optional Information

Share only what you're comfortable with. You can include current medications, allergies, medical history, accessibility needs, or anything else that would help us prepare for your visit.

Anything Else We Should Know? (Optional)

Yes, please contact me about my patient registration. I understand my information will be kept private and handled in accordance with the clinic's privacy policy. *

Your information is sent securely to our North York care team.