Online Application – East Lambton – North Lambton Community Health Centre

Location*

North Lambton Community Health Centre

Before filling out the application please read and understand these specifications:

Clients must live in the services area:
• South of Lake Huron
• North of Highway 402
• West of Ausable River Cut / Lambton County Boundary
• East of County Road 26 (Mandaumin Road)

Specific populations:
• First Nation Persons
• Seniors (65 years of age and older)
• Rural Families
• Families with Young Children (5 years of age and younger)

Applicants who do not have a family doctor will be put onto the waiting list ahead of those who do have a family doctor. The Centre takes in applicants from the waiting list based upon the availability of time in the workloads of the physicians and nurse practitioners.

When the Centre is able to take in new clients, and your application is selected, the Centre will send you a letter requesting you to book an appointment. This first mandatory appointment is to meet you, review your application with you, and to explain how the Community Health Centre works. This meeting helps both you and the Centre determine if a good health care relationship can be established.

Please know that your application may be on the waiting list for several months. If you find a family doctor or if any other information on your application changes, (especially phone numbers and/or addresses), please call the Centre to let us know.

West Lambton Community Health Centre

Before filling out the application please read and understand these specifications:

Clients must live in the service area:
• South of Lake Huron
• North of Whitebread Line / Kent Line
• West of Mandaumin Road
• East of St. Clair River

Specific populations:
• Youth (ages 16 to 24)
• Seniors (65 years of age and older)
• Persons with Low Incomes
• Persons with a Moderate Mental Illness
• First Nations

Applicants who do not have a family doctor will be put onto the waiting list ahead of those who do have a family doctor. The Centre takes in applicants from the waiting list based upon the availability of time in the workloads of the physicians and nurse practitioners.

When the Centre is able to take in new clients, and your application is selected, the Centre will send you a letter requesting you to book an appointment. This first mandatory appointment is to meet you, review your application with you, and to explain how the Community Health Centre works. This meeting helps both you and the Centre determine if a good health care relationship can be established.

Please know that your application may be on the waiting list for several months. If you find a family doctor or if any other information on your application changes, (especially phone numbers and/or addresses), please call the Centre to let us know.

East Lambton Community Health Centre

Before filling out the application please read and understand these specifications:

Clients must live in the service area:
• South of Highway 402
• West of Ausable River Cut I Lambton County Boundary
• Northeast of Mandaumin Road and Churchill Line intersection
• Northeast of Forest Road and Aberfeldy Line intersection

Specific populations:
• First Nation Persons
• Seniors (65 years of age and older)
• Rural Families
• Families with Young Children (5 years of age and younger)

Applicants who do not have a family doctor will be put onto the waiting list ahead of those who do have a family doctor. The Centre takes in applicants from the waiting list based upon the availability of time in the workloads of the physicians and nurse practitioners.

When the Centre is able to take in new clients, and your application is selected, the Centre will send you a letter requesting you to book an appointment. This first mandatory appointment is to meet you, review your application with you, and to explain how the Community Health Centre works. This meeting helps both you and the Centre determine if a good health care relationship can be established.

Please know that your application may be on the waiting list for several months. If you find a family doctor or if any other information on your application changes, (especially phone numbers and/or addresses), please call the Centre to let us know.

Name*

First Last

Date of Birth*

Gender*

Male
Female
Other

Please specify

Preferred Pronoun (Optional)

He/Him
She/Her
Them/They

Address*

Street Address Address Line 2 City Province Postal Code

Home Phone*

Work Phone

Other Phone

Are you a Canadian Citizen*

Yes
No

What is your Citizenship?*

Do you have a valid Ontario Health Card?*

Yes
No

Health Card #*

Are you a permanent resident of our catchment area?*

(see above for description of area)

Yes
No

Did a particular community agency refer you to our Health Centre?*

Yes
No

Which Agency?*

Who is your contact person(s) with this agency?*

Is there a Consent Form from the referring agency attached?*

Yes
No

Consent Form

Do you presently have a Family Doctor?*

Yes
No

Doctor's Name*

Doctor's City*

Who was your last Family Doctor?

When did you last see this Doctor?

Research has shown that certain groups of people in the Lambton-Sarnia area have difficulties obtaining Primary Health Care. Therefore, the following populations will have priority with regards to acceptance:*

(Please check all that apply to you)

Senior (age 65 & older)
Rural Family
Family with Young Children (under age 5)
First Nation
Person with a disability
LGBTQ
None

Which types of transportation do you use most often:*

(you may check more than one)

Walking
Bicycle
Bus
Taxi
Friend with a car
Family with a car
Your own car

Please explain the best way for us to contact you:*

We also recognize that there are some medical conditions that may need to take priority on the waiting list. To allow us to prioritize applications and select the most appropriate provider, please complete the following:*

Examples of Medical Conditions: (Please check all that apply)

What kind of Cancer?*

What kind of Addiction(s)?*

Other serious medical or special circumstances not listed above (please explain))*

Please list all medications you are currently taking:

(including non-prescription medications)

Medication Name	Prescription? (Yes or No)	If prescription medication, who provides the prescription?

Which pharmacy do you use to have your prescriptions filled?

I understand that all personal health information on this form is confidential and will be treated according to the North Lambton Community Health Centre's Privacy Policy, which is available to me on request.

I understand and consent to the use of my personal health information on this form by the North Lambton Community Health Centre’s Wait List Management Committee to determine my eligibility for primary care at the Centre.

If my application is accepted, I agree to have my medical records transferred to the North Lambton Community Health Centre. I understand the health care system is under great pressure and “double-doctoring” is not acceptable.

I understand that if I have given false information, I will be excluded from being accepted into this practice. I hereby declare that the above information is up-to-date and correct.

I understand that all personal health information on this form is confidential and will be treated according to the West Lambton Community Health Centre's Privacy Policy, which is available to me on request.

I understand and consent to the use of my personal health information on this form by the West Lambton Community Health Centre’s Wait List Management Committee to determine my eligibility for primary care at the Centre.

If my application is accepted, I agree to have my medical records transferred to the West Lambton Community Health Centre. I understand the health care system is under great pressure and “double-doctoring” is not acceptable.

I understand that if I have given false information, I will be excluded from being accepted into this practice. I hereby declare that the above information is up-to-date and correct.

I understand that all personal health information on this form is confidential and will be treated according to the East Lambton Community Health Centre's Privacy Policy, which is available to me on request.

I understand and consent to the use of my personal health information on this form by the East Lambton Community Health Centre’s Wait List Management Committee to determine my eligibility for primary care at the Centre.

If my application is accepted, I agree to have my medical records transferred to the East Lambton Community Health Centre. I understand the health care system is under great pressure and “double-doctoring” is not acceptable.

I understand that if I have given false information, I will be excluded from being accepted into this practice. I hereby declare that the above information is up-to-date and correct.

I agree with the above statements, and acknowledge that by checking this box it will act as a digital signature.*

I Agree