Government of Ontario: Ministry of Health and Long-Term Care

Primary Health Care New Patient Declaration

Do not mail this form to the ministry. This form must remain in the physician’s office for audit purposes.

Please complete this form if you are a new patient of a primary care physician and have signed a Patient Enrolment and Consent to Release Personal Health Information form. If you are signing on behalf of a child or dependent adult, and have completed a Patient Enrolment and Consent to Release Personal Health Information form on their behalf, complete the applicable sections below.

Declaration

I am signing on behalf of (check the applicable boxes)
myself (complete sections A and C)
the children listed below of whom I am the parent or guardian (complete sections B and C)
the dependent adult (s) listed below for whom I have a power of attorney for personal care (complete sections B and C)

I hereby declare that the patient(s) named below does/do not have
a family physician due to one or more of the following circumstances:
(check applicable boxes)
The patient’s family physician has moved to another community.
The patient has moved to another community.
The patient’s physician is no longer available due to illness/death/retirement.
The patient’s physician is no longer available due to change of practice type.
Up until now the patient has not had, or felt the need for a family physician.

Section A: Patient Information

First Name
Last Name
Health Number

Section B: Children and Dependent Adults

First Name
Last Name
Health Number
First Name
Last Name
Health Number

For additional children / dependent adults, please complete another New Patient Declaration form.

Section C: Signature and Date

Signature
Date (yyyy/mm/dd)

Section D: Physician Signature and Date

I declare that the above patient is not presently a patient of mine or, to the best of my knowledge, of any other physician in the primary care group with which I am affiliated (if applicable). I also declare that no child listed (if any) is a newborn of any existing enrolled or non-enrolled patient of mine, or to the best of my knowledge, of any other physician in the primary care group with which I am affiliated (if applicable).

I agree to accept the above-noted patient(s) into my practice and to provide ongoing health care to the patient(s) from the date of this document. I will keep this document available on file in my primary office location and will provide copies to the Ministry of Health and Long-Term Care as required for verification purposes.

Physician Last Name (print)

First Name (print)

Physician Signature
Date (yyyy/mm/dd)

4367-84