DEREGISTER FROM YOUR PHYSICIAN AT MAGENTA HEALTH

If you have elected to leave the care of your Magenta Health physician - please fill out this form for each patient who should be deregistered.

IMPORTANT: Due to the high demand for family doctors at all three clinic locations, our standard policy is that patients who elect to leave the clinic and the care of their Magenta Health physician will not be able to re-join the clinic for a minimum of 3 years.

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

OHIP Number

Phone Number

(###)

###

####

Confirmation

I confirm that I would like to deregister from my Magenta Health Physician

I am deregistering because...

If multiple of these apply, please just select the one most relevant.

Acknowledgement

I understand that my deregistration is not complete until I have received a confirmation email, and that processing may take between 5 - 10 business days.

If you wish to request a copy of your Medical Records, please visit this page here.