Fax this form to 905 319 3670

Welcome to Bayridge, please provide the following information:

Name________________________________________________

Address_____________________________________________________

City____________________ Postal Code___________ Birthdate_______________

Phone (Home)________________________ (Business)____________________

Health Insurance No. with Version Code ________________________________
You must bring your valid OHIP card with you or be billed for the visit!

Date of appointment with Dr. Mullen ________________________________

Complete name and full postal address of Family Doctor, so a report can be sent.

_________________________________________________________________

Bayridge provides email newsletters and the occasional notice regarding upcoming conferences. Bayridge will not use your address for any other purpose, and will never give or sell your address to any other party. If you would like to receive email notices from Bayridge, please provide your email address:

Email ___________________________________________________________

You must mail or fax this form (Use the fax number above) to the Center at least 1 week before your initial appointment. You must also confirm your appointment 1 week in advance by phone. If we don't hear from you, your appointment will be given to someone on the cancellation list.

If an appointment is not kept and no notice has been given 24 hours in advance, the cost of the missed appointment ($40-$200) will be billed directly to the patient.

Treatment is on an outpatient basis only. Patients needing hospitalization will be transferred to the care of a psychiatrist. In the event of an emergency outside of office hours or when Dr. Mullen is not available, patients should contact their Family Doctor or go to the nearest Emergency Dept.

Prescription renewals are done at the time of your appointment and not by telephone. In exceptional circumstances, prescriptions may be renewed upon receipt of a faxed request from a pharmacist. There is a $5.00 charge for this service. Renewals are not available when Dr. Mullen is not in the office.
I have read, understood and agree to the above information.

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Signature

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Date