Patient registration (Special)

This registration form is for use only in the following situations:

a prospective patient was booked for an intake appointment without going through our standard registration process.
a patient was provided this link by Dr. Danayan / Danforth Pediatrics staff to pre-register with Dr. Mitsuki.

If you have been asked to complete this form, please do so once for each named individual. For example, if you were asked to complete this form for your two children, please complete and submit this form twice, once of each child.

Acknowledgement

I am ...

Your OHIP Card Information

Please fill in the below fields with the information as it appears on your OHIP card. We are required to submit this data to the MOH to confirm your card is valid. There is another optional section below this one if you identify differently than what is listed on your OHIP card. If that is the case, please fill out both sections.

First / Given Name(s) of Patient

If you have a middle name on your card, please include it here as well

Last Name of Patient

Patient's 10 digit health number?

e.g. 0123456789, 3821694372.

Patient's Version Code

It is usually two characters, e.g. TA

Date of Birth?

YYYY

OHIP Issue Date

Labelled as "ISS/DEL" on your card

YYYY

OHIP Expiry Date

Labelled as "EXP/EXP" on your card

YYYY

Your Identity

This section is optional, if any of the information on this form is not representative of how you identify

The name you go by

(optional - please fill in if you do not go by the name on your OHIP card)

Gender identity, if you are comfortable disclosing

(optional)

Other Information required for Registration

If the physician is able to accept you into their practice, we will use this information to add you to our system, and contact you with an invitation to book a "meet and greet" style intake appointment. If they are not able to accept you into their practice, we will use this information to contact you to let you know that as well.

Sex assigned at birth

Street Address (including unit number, if applicable)

City

Province

Postal Code

e.g. A1A 1A1

Email Address

Primary Personal Phone Number

(E.g. home phone)

(###)

###

####

Secondary Personal Phone Number

(E.g. cell phone)

(###)

###

####

If your intake appointment is already booked, please provide the date:

YYYY

Please provide the name of the physician to whom you wish to be assigned:

I agree to Magenta Health Inc. contacting me by email

Yes