Complete this REFERRAL FORM for the North York Community Care Clinic (NYCCC) - Nurse Practitioner Led Clinic for Primary Care Clinic. You may self-refer as a patient.
We use this information to determine your eligibility for our program. We may contact you for more details and clarification. Please note that completion of this form does not guarantee you service at our clinic, nor acceptance in to the NP program. This just expedites the Intake process.

Patient Information:

Enter 000 if you do not have a health card.

Alternatively, you may fax records to 416.848.7773 (GWC T.38 Fax)

Select all categories that apply to the patient. This information is used by Ontario Health Teams to prioritize certain population groups.
Click here to read about eligibility criteria
By submitting this form, you declare that you have permission to provide this personal information. The Nurse Practitioner Primary Care Clinic is operated by Get Well Clinic, on behalf of the North York Toronto Health Partners, an Ontario Health Team. We use the following initial information to determine eligibility for the program, as well as obtain preliminary sociodemographic information that may be used for tailoring care to priority populations.
By submitting this form, you declare that the patient has consented to collection and submission of their personal information for consideration in to the Nurse Practitioner Primary Care Clinic. This data may be used by Get Well Clinic and other members or organizations of an Ontario Health Team such as North York Toronto Health Partners, to coordinated and provide integrated care. This data may also be used for quality improvement, and health system monitoring, planning, and evaluation.
By submitting this form, you declare that the patient has consented to receive communications from Get Well Clinic and any member of an Ontario Health Team such as North York Toronto Health Partners, through telephone, text, SMS, email, or any other electronic form of communication.
Enter the name of the person who completed the form. A patient may self-refer and complete this form.