Registration Form

Patient Registration & Clinic Consent Form

Please fill out all sections completely below to register with Truwell Medical Services and acknowledge our clinic policies.

First Name *

Last Name *

Date of Birth (DD-MM-YYYY) *

Gender

Phone Number *

Email Address *

Residential Address *

Emergency Contact Full Name *

Relationship to Patient *

Emergency Contact Phone *

Provincial Health Card Number / Insurance ID *

Do you have any known drug allergies?

Current Medical Conditions / Medications

I acknowledge and agree to Truwell Medical Services clinic policies, cancellation terms, and patient code of conduct.

I consent to receive electronic communications, appointment reminders, and health test notifications via email.

Electronic Signature (Type Full Legal Name) *

Local medical care in Waterloo, Ontario, with clear information and easy ways to contact the clinic.

Quick Links

Contact Info

280 Lester St
Waterloo, ON N2L 0G2

Patient Note

If you are experiencing a medical emergency, call 911 or visit the nearest emergency department.