PATIENT REGISTRATION (Dr. Stephen Pomedli)

this registration form is for use only in the following situation:

you are a previous patient of Dr. Pomedli who would like to be transferred to Magenta Health

If you have been asked to complete this form, please do so once for each named individual. For example, if you were asked to complete this form for your two children, please complete and submit this form twice, once of each child.

Acknowledgement

First / Given Name(s) of Patient

If you have a middle name on your card, please include it here as well

Last Name of Patient

What is the patient's 10 digit health number?

e.g. 0123456789, 3821694372

What is the patient's Version Code?

It is usually two characters, e.g. TA

What is the patient's Date of Birth?

MM

DD

YYYY

OHIP Issue Date

Labelled as "ISS/DEL" on your card

MM

DD

YYYY

OHIP Expiry Date

Labelled as "EXP/EXP" on your card

MM

DD

YYYY

The name you go by

(optional - please fill in if you do not go by the name on your OHIP card)

Gender identity, if you are comfortable disclosing

(optional)

Sex assigned at birth

Street Address (including unit number, if applicable)

City

Province

Postal Code

e.g. A1A 1A1

Email Address

Primary Personal Phone Number

(E.g. home phone)

(###)

###

####

Secondary Personal Phone Number

(E.g. cell phone)

(###)

###

####

I want to continue to be a patient of Dr. Steve Pomedli and register at Magenta Health.

Yes

I have reviewed information about Magenta Health.

Yes

I consent for Magenta Health to contact me directly via email for administrative purposes.

Yes

I consent for my medical records to be securely transferred to Magenta Health.

Yes

HEALTH NUMBER AND VERSION CODE

The following images explain what your health number and version code are, for different health card versions. It is important that this information be provided to us correctly so that we may properly validate your OHIP.