Roster Form

Collection of the information on this form is under the authority of the Ministry of Health Act, subsection 6(1) and (2) and the Health Insurance Act, R.S.O. 1990, c. H.6, s.4(2)(b) and (f), 4.1(1) and (2), 10 and 11(1). For information about collection practices, contact the Director, Registration and Claims Branch, Box 48, 49 Place d'Armes, Kingston ON K7L 5J3, INFOline tel. 1 888 218-9929 or by mail through the addresses listed for local Ministry of Health and Long-Term Care offices.

Last Name *

First Name *

Second Name

Health Number * (10 digits)

Version Code *

Mailing Address *

Date of Birth * (yyyy/mm/dd)

Sex *

M F

Residence Address

Send notices from my family doctor's office to me by: *

Regular mail Email (if possible)

Email Address

A Dependent A Information

Last Name

First Name

Second Name

Health Number

Version

Date of Birth

Sex

M F

I am this person's:

B Dependent B Information (Optional)

Last Name

First Name

Second Name

Health Number

Version

Date of Birth

Sex

M F

I am this person's:

Section 3 — Signature

I have read and agree to the Patient Commitment, the Consent to Release Personal Health Information and the Cancellation Conditions. I acknowledge that this Enrolment is not intended to be a legally binding contract and is not intended to give rise to any new legal obligations between my family doctor and me.

I am signing on behalf of (check all that apply): *

myself child(ren) dependent adult(s)

My Name (Last Name) *

My Name (First Name) *

Signature * (Draw with finger / mouse)

Home Telephone No.

Work Telephone No.

Date * (yyyy/mm/dd)

Section 4 — Family doctor information

Select Family Doctor / Choisir le médecin: *

Dr. Mina Tasharofi Kia Dr. Muhammad Shahrukh Ali Khan

DR. MINA TASHAROFI KIA, WRELLEN FHO

108-4190 FINCH AVE. EAST
TORONTO, ON, M1S 4T7

BILLING NO.: 023530
GROUP NO.: 0BAWC

Family Doctor's Signature

Date: 2026-09-24

Ontario Ministry of Health - Patient Enrolment Terms

Patient Commitment

Consent to Release Personal Health Information

Cancellation Conditions

Submitting Enrolment...