Pictou County Health Authority

Registration Form for Patients Seeking a Family Doctor

* – Required fields.

Name*

Address*

Telephone Number*
(xxx)xxx-xxxx

Email*

Date of Birth*
mm/dd/yyyy

Name of last or most recent family doctor*

How many people are you registering?*
Self
Family

Other

Registration forms will be forwarded to family doctors in Pictou County who have agreed to use this process
You will be contacted directly by the family doctor’s office if/when an appointment is available
Submission of this registration form does not guarantee that you will be accepted into a doctor’s practice
The family doctor is responsible for the final decision of acceptance into a practice