Patient Registration

Your information

This form takes about 3 to 5 minutes. Fields marked required help us verify identity and prepare safely.

Basic details

Full name * Email * Phone * Date of birth * Health card / Insurance ID Preferred campus *

Address

Street * City * Province / State * Postal / ZIP code * Country *

Care preferences

Primary service * Preferred doctor Notes

Emergency contact

Contact name * Contact phone * Relationship

Consent

I agree that EternaMed may contact me to arrange care and confirm bookings * I have read the privacy policy * Send me helpful updates and health tips (optional)

We will email you a confirmation

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