New Patient Registration Form

First Name / Last Name

Date of Birth

Health Card Number

Health Card Expiry Date

Email address

Phone Number

Gender

Male Female Non-binary

Physical Address, City/Town, Province/Territory, Postal Code

Name and Location of previous family doctor

Emergency Contact (Name, Phone Number, Relationship)

Would you like to use Danton Pharmacy for your medications needs?

YES, I would like to use Danton Pharmacy.

No, I would like to keep my current pharmacy.

Which clinic location would you like to register with?

Danton Medical Center- Mississauga (7025 Danton Promenade, Mississauga, ON L5N 5E5) Danton Medical Center- Oakville (3265 Carding Mill Trail, Oakville, ON L6M 5P7)

I consent that I am applying to register as a new patient looking for a family doctor and I have read the policies listed below and I agree to follow all the clinic policies as posted from time to time on the website www.danton.ca and I also recognize that Danton Medical Centre doesn't tolerate any kind of verbal, sexual or physical abuse towards any employees or doctors.

I understand that this application does not guarantee that I will get accepted as a patient.

Click here to read the New Patient Information.

Click here to review our Frequency Asked Questions.

Click here to review our Uninsured Services.

Please review our website www.danton.ca and contact our office in case you have any other questions.

If I got accepted as a patient, I consent that if I violate the clinic policies, I will be terminated as a patient immediately.

Your information will be encrypted.

New Patient Registration Form

New Patient Registration Form

New Patient Registration Form

Danton Medical Centres