Bastion Medical Centre - Waiting List

On completion of this form you will be placed on a waiting list for Bastion Medical Centre.  All the information submitted is confidential and will not be shared beyond Panacea Medical Group without your permission.  As soon as a space is available you will be contacted. Thank you for taking the time to complete this form.  
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Must be under the age of 19 years old. Please enter the data in the following order: First Name; Last Name; Date of Birth (MM/DD/YYYY); Care Care Number; Relationship to applicant.
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