New Patients Looking For A Family Doctor

Please submit your details here and one of our staff will contact you. Fill in a SEPARATE form for EACH family member who wants to register

Sign up for a Family Doctor

Full Name (EXACTLY as it appears on your Healthcard)*

Phone (ideally cell number)*

Date Of Birth (EXACT FORMAT: YYYY-MM-DD)*

Gender*

Email*

Full Address*

Healthcard Details (10 numbers AND 2 letters, eg. 0123456789 AB)*

List of previous/current medical conditions and operations (eg. depression, sinus surgery)*

List of current regular medications with dosing (eg. Eltroxin 50mcg once daily) - We do NOT prescribe stimulants/narcotics (eg. for ADHD/Chronic pain)*

Weight in kilograms*

Height in centimetres*

Reason you want a doctor (eg. specific medicine) and the name of the doctor ONLY if you've been referred to a SPECIFIC one. We do NOT assess for ADHD.*

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Attention Patients

Dr. Ajay Chanana will be covering for Dr. Shafi while he is away. Please book your appointments with Dr. Chanana instead of Dr. Shafi. Thank you!

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