Patient Registration

New Patient Registration

Welcome to Benco Medical Centre! Please complete this form. Your information is protected under PHIPA (Ontario).

First Name

Last Name

Date of Birth

Gender

Health ID Number

Version Code

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Email

Phone

Reason for Booking

I consent to have this website store my submitted information so they can respond to my inquiry

Multi-specialty clinic that offers walk-in services, family practice and specialist services.

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