New Patient Intake Form

Last Updated: October 2025

Welcome to Daniel Medical Centre’s Virtual Appointment booking system. Before proceeding, please review and confirm the following terms and conditions. These are required under Ontario regulations for virtual care.

Services: Our virtual appointments provide access to non-emergency primary care, wellness, and counseling services through secure telemedicine technology.

Privacy: Daniel Medical Centre complies with the Personal Health Information Protection Act (PHIPA) and other applicable privacy laws. For questions about privacy, contact [email protected].

Consent: By agreeing to this form you understand and agree to:

• Daniel Medical Centre’s Terms of Use and Privacy Policy.
• The risks and limitations of telemedicine, including technological limitations.
• Your consent remains valid for the duration of your use of our virtual services.

Marital Status

Emergency Contact Information

Medical History

Lifestyle Information