Orleans Family Clinic

613-830-5111
Fax: 613-830-5112
Mon - Fri 9:00 - 17:00

WAITING LIST FORM

First Name *

(As it appears in your Health Card)

Last Name *

(As it appears in your Health Card)

Date of Birth *

Health Card Number *

Street Address *

City *

Postal Code *

Province *

Phone Number *

Email Address *

IMPORTANT NOTICE:
Please note that being on the waiting list doesn't guarantee your acceptance to the practice. Therefore, please do not contact the clinic to ask about the status of your application, we will contact you directly when you have been accepted to our practice.

reCAPTCHA Invisible *

Name