Join Our Kitchener Practice

Mango Tree FHT presently has a waiting list to become a patient. Please fill out the online form to be on the waiting list

First Name, Last Name (required)

Street Address (required)

City (required)

Postal Code (required)

Age

Preferred Email (required)

Home #

Mobile #

Are you registered with Health Care Connect?(required)

Previous Family Doctor (required)

Medications (required)

If you are not currently taking any medications, please write "None" in the field above.

Medical Conditions

Additional Message

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