New Patient Registration

Please submit the form below in order to register with a Family Doctor at WellOne Medical Centre.

We will email you a link to our online booking portal for you to book your appointment.


Name *
Name
Date of Birth *
Date of Birth
e.g. 0123456789, 3821694372 (see below for more information)
e.g. TA or N, or simply leave blank (see below for more information)
Primary Phone Number *
Primary Phone Number
If you have a preference as to which Family Doctor you would like to register with, please indicate your choice here.
Disclaimer *
I have read and agree to the Clinic Policies (available on our "About Us" page ). I certify all information provided to WellOne Medical Centre to be true and acknowledge that by clicking this box that I have given consent to release this information to be used in the clinic only and will not be shared externally. I agree to Magenta Health Inc. contacting me by email. IF THIS IS A MEDICAL EMERGENCY, PLEASE CALL YOUR LOCAL EMERGENCY SERVICE (911) TO GET PROMPT MEDICAL ATTENTION. DO NOT RELY ON ELECTRONIC COMMUNICATIONS FOR ASSISTANCE REGARDING YOUR IMMEDIATE, URGENT MEDICAL NEEDS. THIS FORM IS NOT DESIGNED TO FACILITATE MEDICAL EMERGENCIES