Use this form if you have dependents or family members you wish to register. The Family Health Clinic serves family members of students, visiting scholars, and post doctorates who are at the University of Waterloo with their families and do not have a family doctor in the community.

If you are a student seeking medical care, please come to Health Services and register in person at the Student Medical Clinic.

Information and privacy: questions regarding the collection of information on this form can be directed to the form administrator.

Your information

Your surname or family name
Your given name
(if different from your given name)
Contact information
Please use the format 000-000-0000
Affiliation with the University of Waterloo * (required)
Please enter your date of birth using the format DD/MM/YYYY
Please indicate whether you currently have health coverage in Canada. (Residents of Quebec, please select "no" and proceed with the questions.)

Family member registration

You can register up to five family members using this online form. If you have additional family members to add, please notify staff at your intake appointment.

Do you have family members you wish to register? * (required)
First family member
Surname or family name
Given name
Please use the format DD/MM/YYYY
Gender * (required)
Relationship to you * (required)
Please use the format 000-000-0000
Note: this person must be at the same address and phone number
Second family member
Surname or family name
Given name
Please use the format DD/MM/YYYY
Relationship to you * (required)
Please use the format 000-000-0000
Note: this person must be at the same address and phone number
Third family member
Surname or family name
Given name
Please use the format DD/MM/YYYY
Gender * (required)
Relationship to you * (required)
Please use the format 000-000-0000
Note: this person must be at the same address and phone number
Fourth family member
Surname or family name
Given name
Please use the format DD/MM/YYYY
Gender * (required)
Relationship to you * (required)
Please use the format 000-000-0000
Note: this person must be at the same address and phone number
Fifth family member
(Surname or family name)
(Given name)
Please use the format DD/MM/YYYY
Gender * (required)
Relationship to you * (required)

If you have additional family members to add, please notify staff at your intake appointment.

Additional contact information

Your family doctor
If you have a family doctor, please provide contact information
Please use the format 000-000-0000.

If you are unable to use this online form, you may fill out a printable version:

Please bring the forms to the Family Health Clinic reception desk in Health Services.

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