ALondon Nurse Practitioner-Led Clinic, Health Zone

Please DO NOT CALL the clinic to follow-up on our wait list form status.

I certify that the information below is correct to the best of my knowledge

I acknowledge that completing this registration form does not guarantee that I will become a patient at the Health Zone Nurse Practitioner-Led Clinic

I acknowledge that I understand I will not become a registered patient until AFTER attending an intake appointment with a Nurse Practitioner wherein my health information will be reviewed, and a final decision will be made whether the Health Zone Nurse Practitioner-Led Clinic will accept me as a patient based on the Nurse Practitioner scope of practice

Full Name

Birthdate

Sex assigned at birth

Pronouns

Street Address

City

Postal Code

Health Card #

Phone Number

Will any other family members be applying with you?

Yes

Do you have any family members that are already registered with Health Zone?

Yes

**Please note that you will need to fill out a separate wait list form for EVERY person in your family applying**

After you have completed the form, please contact our clinic at 226-777-1988 ONLY if your contact information changes.

Thank You
Health Zone NPLC Team

New Patient Wait List

Please DO NOT CALL the clinic to follow-up on our wait list form status.