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Welcome to Ray Of Hope Medical Centre, please use the form below to tell us more about yourself.

Registration Form

Your Name *

First

Last

Manitoba Registration No. ( 6 Digits ) *

Manitoba Personal Health I.D. ( 9 Digits ) *

Your Address *

Please enter the Street address, City, Province, and Postal Code

Your Date of Birth *

Your Gender *

Cell Phone Number *

Work / Home Phone Number

Email

Emergency Contact Name

First

Last

Emergency Contact Relationship

Emergency Phone Number

Please Select Your Reference

Patient Medical Health History *

Patient Surgical History

Allergies that you might have

Medications *

If you have any Medication that you usually use, please list it here. Please include all "Over The Counter" medication as well.

Your Family Health History

Do you have a Family Doctor

If YES, what is your Family Doctor's Name?

Why you are willing to change your current Family Doctor

Other Information

How did you hear about us?

Email