Register | Family Doctor Finder | Manitoba Health, Seniors and Active Living

Personal Information

PHIN

Given name (First name)

Surname (Last name)

Gender

Date of birth (DD-MM-YYYY)

Email address

Daytime phone number

Phone type

Secondary phone number

Phone type

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

Accessibility needs

Preferred language of program communication

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

Miscellaneous Information (optional)

Access Code

Additional Information (max 150 characters)

Mailing Address

Unit/Apt #

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

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

Additional Person

Personal Information

PHIN

Given name (First name)

Surname (Last name)

Gender

Date of birth (DD-MM-YYYY)

Email address

Daytime phone number

Phone type

Secondary phone number

Phone type

Does this individual currently have a	Yes
family doctor or nurse practitioner?	No

Accessibility needs

Preferred language of program communication

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

Miscellaneous Information

Do you have this person’s permission	Yes
to register him or her?	No

Why are you registering on his or her behalf?

Indicate the reason for why you are registering on this persons behalf:

You are the applicant's…

Are you the contact person for this request? No Yes

Access Code

Additional Information (max 150 characters)

Mailing Address

Same address as previous

Unit/Apt #

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 preferred area/community

Select second most
preferred area/community

Preferred language of provider

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

Consent

How did you hear about the program?

Would you be open to being contacted in the future to discuss your
experience with the program and/or primary care in Manitoba?

Yes
No

By checking this box, I give Manitoba Health, Seniors and Active Living (MHSAL) and/or my regional primary care connector
permission to leave/send a private message at/to any of the phone numbers or email address listed above.
Please note that the privacy and security of email communication cannot be guaranteed. Emails can be forwarded, intercepted, circulated, stored and even changed without the knowledge or permission of either the sender or recipient. Emails can also introduce viruses and other threats into a computer system. By consenting to be contacted by MHSAL by email, you affirm that you understand and accept the risks associated with communication by email.

Please also note that for the purpose of matching you with a provider, your Personal Health Information Number (PHIN) may be shared with your regional health authority and/or a primary care clinic.

Manitoba Health, Seniors and Active Living

Family Doctor Finder Online Registration

Connecting Me to My Primary Care

My Information

Personal Information

Miscellaneous Information (optional)

Mailing Address

Preferences for a Health Care Provider

Additional Person

Personal Information

Miscellaneous Information

Mailing Address

Preferences for a Health Care Provider

Consent

Service delivery may be affected in light of COVID-19. For additional information, visit: manitoba.ca/covid19/