Family Doctor Finder | Manitoba Health

Personal Information

Note

If you are a legal guardian, health care provider, or a person registering on behalf of someone, please enter your information here. Client information is further down below. Please ensure that you have the client's consent before registering.

PHIN *

Given Name (First Name) *

Surname (Last Name) *

Gender *

Date of Birth (DD-MM-YYYY) *

E-Mail Address

Daytime Phone Number *

Phone Type *

Secondary Phone Number (Optional)

Phone Type (Optional)

Do you currently have a family doctor or nurse practitioner? * Yes No

Accessibility Needs (Optional)

Preferred Language of Communication *

Although the program will strive to provide service in your preferred language, there may be times when this is not operationally feasible.

Mailing Address

Unit/Apt # (Optional)

Street Address/P.O. Box *

Town/City *

Postal Code *

Country *

Province *

Preferences for a Health Care Provider

Preferred gender of provider

Preferred provider type

Select your preferred area/community *

Select your second most preferred area/community *

Preferred language of provider (Optional)

Although the program will strive to find a provider who can communicate in your preferred language, we cannot guarantee this aspect of the service.

Miscellaneous Information

Access Code (Optional)

Additional Information (max 285 characters) (Optional)

Remaining characters: 285

Personal Information

PHIN *

Given Name (First Name) *

Surname (Last Name) *

Gender *

Date of Birth (DD-MM-YYYY) *

E-Mail Address

Daytime Phone Number *

Phone Type *

Secondary Phone Number (Optional)

Phone Type (Optional)

Do you currently have a family doctor or nurse practitioner? * Yes No

Accessibility Needs (Optional)

Preferred Language of Communication *

Although the program will strive to provide service in your preferred language, there may be times when this is not operationally feasible.

Mailing Address

Same address as previous

Unit/Apt # (Optional)

Street Address/P.O. Box *

Town/City *

Postal Code*

Country *

Province *

Preferences for a Health Care Provider

Same preferences as previous

Preferred gender of provider

Preferred provider type *

Select your preferred area/community *

Select your second most preferred area/community *

Preferred language of provider (Optional)

Although the program will strive to find a provider who can communicate in your preferred language, we cannot guarantee this aspect of the service.

Miscellaneous Information

Do you have this person's permission to register them? * Yes No

Why are you registering on this person's behalf? *

Indicate the reason why you are registering on this person's behalf *

Remaining characters: 200

What is your relationship with this person? *

Are you the contact person for this individual? * Yes No

Access Code (Optional)

Additional Information (max 285 characters) (Optional)

Remaining characters: 285

Family Doctor Finder Online Registration

Connecting Me to My Primary Care

My Information

Note

Additional Person

Family Doctor Finder Online Registration

Connecting Me to My Primary Care

My Information

Note

Additional Person

Consent