New Patient Application (March 2023)

All applications are subject to review. All applications will be considered. Submit only 1 application per household/family.

Please consider becoming a member of the Community Health Association (Regina) Limited to receive clinic correspondence and news.

* Members of the clinic must be 18 years of age

You will be contacted if there is a change in the status of our patient capacity.

Thank you for your submission

Full LEGAL Name (First and Last) *

Phone Number (000-000-0000) *

E-mail

Do you currently have a family physician? *

If YES, please indicate your reason(s) for wishing to change from your current physician to one at the Regina Community Clinic

Are you a sole applicant? *

If NO, please list all family members and their relationship to you. Please list full LEGAL names (first and last)

Are you an immediate family member of RCC staff? *

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