NEW PATIENT REGISTRATION FORM – Albany Medical Clinic

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(416)-461-9471

807 Broadview Ave, Toronto, Ontario M4K 2P8

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Our Medical Staff
- Family Doctors
- Specialists
Our Services
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- Walk-in Clinic Hours
- Walk-in Clinic – Key Information During COVID-19
Patient Info
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Immunization
Submit Photos
- How to Submit Photos
Message or Submit Documents
COVID-19 KEY RESOURCES

Menu

Home
Our Medical Staff
- Family Doctors
- Specialists
Our Services
Walk-in Clinic
- Walk-in Clinic Hours
- Walk-in Clinic – Key Information During COVID-19
Patient Info
Contact Us
Immunization
Submit Photos
- How to Submit Photos
Message or Submit Documents
COVID-19 KEY RESOURCES

Thank you for your interest in the Albany Medical Clinic!

Please complete the following form if you would like to be added to our Wait List. You can use the form to add family members as well.

A member of our team will contact you within 1 week to review your completed Form and advise you about the status.
First Name*
Last Name*
Date of Birth*
MM slash DD slash YYYY
Sex*
Apt/Suite #
Address*
City*
Postal Code*
Contact #*
Contact Email*
Physician Preference*
- First Available
- Male
- Female
Do you wish to add other family members to the wait list?*
- Yes
- No
This field is hidden when viewing the form
Family Members details:
Family Member details:
First Name*
Last Name*
Date of Birth*
MM slash DD slash YYYY
Sex*
Apt/Suite #
Address*
City*
Postal Code*
Contact #*
Contact Email*
Physician Preference*
- First Available
- Male
- Female
Other Family Members you wish to add to the Wait List?*
- Yes
- No
This field is hidden when viewing the form
Family Members details:
Family Member details:
First Name*
Last Name*
Date of Birth*
MM slash DD slash YYYY
Sex*
Apt/Suite #
Address*
City*
Postal Code*
Contact #*
Contact Email*
Physician Preference*
- First Available
- Male
- Female
More family member you wish to add to wait list?*
- Yes
- No
This field is hidden when viewing the form
Family Members details:
Family Member details:
First Name*
Last Name*
Date of Birth*
MM slash DD slash YYYY
Sex*
Apt/Suite #
Address*
City*
Postal Code*
Contact #*
Contact Email*
Physician Preference*
- First Available
- Male
- Female
Tell us how you heard about our Online Patient Registration ?*
- Albany Medical Clinic Staff Member or Physician ?
- Friend or Family Member already at the Albany Medical Clinic ?
Please note: Submission of this Form does not automatically enrol you as a patient of the Albany Medical Clinic
By clicking ‘Accept’, I acknowledge that the Albany Medical Clinic may collect my information, contact me or provide me with information regarding the Albany Medical Clinic and its services.*
- I accept
- I do not accept
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Map of AMC Location

807 Broadview Ave, Toronto, Ontario.
Phone number: 416-461-9471.

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CLINIC DIRECTORY

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ACCESSIBILITY

CLICK HERE for more information on how the Albany Medical Clinic is meeting AODA Accessibility Standards