As a new patient, your consent is required to enroll with Daniel
Medical Centre for primary care services required by Ontario
Section 1 - Patient Commitment
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I will contact my family doctor first when I need primary care
advice or treatment, unless there is an emergency or I am
travelling.
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I will notify the clinic if I move and provide updated contact
information.
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I understand I may de-enroll and enroll with another doctor after
six weeks from signing this form (immediately if I
have moved), and no more than twice per year.
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For enrolled children under 16: my signature confirms I agree to
these terms on their behalf.
Section 2 - Consent to Release Personal Health Information
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I allow my doctor and the Ontario Ministry of Health to exchange
enrollment information, name, address, and phone number.
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I allow the Ministry to release dates of immunizations, preventive
care screenings (pap tests, mammograms), and service records from
other providers.
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This consent ends when my enrollment ends or I cancel in writing
to the Ministry.
Section 3 - Cancellation Conditions
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Enrollment ends if: I cancel, I no longer qualify under the Health
Insurance Act, I enroll with another doctor, or the Patient
Enrollment Model ends.
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Enrollment may end if I consistently fail to meet Patient Commitment
obligations.