Family Doctor Clinic – Accepting New Patient Registrations

Dr. Rabiya Niaz, MD, CCFP

Colborne Medicare

358 Oxford Street East, London, ON N6A 1V7

Thank you! Your enrolment request has been submitted securely. This is a request only and does not guarantee registration. The office will contact you with an appointment upon availability.

New Patient Enrolment

Please complete this form to request enrolment as a new patient. Fields marked * are required.

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Your data is protected Your information is sent over a secure, encrypted connection and stored encrypted in Canadian data centres. Only authorized Procare MD staff can access it, using two-step sign-in.

Personal Information

OHIP Information

Contact Information

Children

For each child, you can choose to request enrolment for them as well.

Referral & Current Physician

Medical History

Please answer every question. Type None if it does not apply to you.

Lifestyle

Declaration

Information provided is strictly confidential.

Concealing any medical information will result in termination of your registration.

This is an enrolment request only and does not guarantee registration, since only a limited number of patients can be registered. The office will contact you with an appointment upon availability.