Online Appointment Account Registration

Please fill in the details below in order to create your booking appointment. Fields marked with an * are mandatory.

First Name*

Last Name*

Date Of Birth (DD/MM/YYYY)*

Cell/Mobile or Home Phone Number*

Address Line 1 (Building No. & Street)*

Apartment No. (if applicable)

City*

Province*

Postal Code*

Insurance Provider*

Health Insurance Number (please include version code)*

Next of Kin Name*

Next of Kin Phone Number*

Email Address*

Password*

Confirm Password*

Do you consent to sharing your email address and cell # (to receive SMS text messages)* Yes No

Input symbols

Use the following link to view our Patient Privacy Policy: https://www.niagarahealth.on.ca/site/privacy-and-confidentiality * Please ensure your email address or mobile phone number is valid and correctly provided as it will be used for account validation, password resets and your Virtual Urgent Care Online Appointments related communication. While Niagara Health will use encrypted email to communicate the above-noted information related to your virtual visit should you choose that option, email is not a secure method of communication and therefore Niagara Health cannot guarantee the security of messages sent by this method. Furthermore the Information and Privacy Commissioner of Ontario does not recognize email as being a secure way to transmit Personal Health Information (PHI). By providing my email address and/or SMS (cell number for text messages), I declare that I have read this information, understand it, and that I consent to receiving communications in this manner from Niagara Health. If I wish to withdraw my consent to communicate by email and/or SMS, I may do so at any time by: 1. logging onto this Online Booking Account 2. Clicking the three horizontal lines (to edit my profile) 3. Selecting “Demographics” 4. Changing my Email/SMS preference to “Denied”