Fill out the information below, or call:
*Phone lines are open Mon-Fri 9AM-8PM, Sat: 9AM-1PM, Sun: Closed.
*For appointments booked using this form, we do not schedule same-day appointments. Once our staff receive your details, they will contact you to confirm your appointment time.
Please note: Electronic message transmission cannot be guaranteed to be secure or error-free, as information could be intercepted, corrupted, lost, destroyed, arrive late or incomplete, or contain viruses. If you prefer, please call our booking line at 1-855-414-2255 with any information containing your personal health information, as the integrity and security of this message cannot be guaranteed on the Internet.
*If you need urgent medical care, please head to your nearest emergency room, or dial 911.
Format: Last Name, First Name
The Phone Number must be able to receive incoming calls
The Health Card Number Must Include the Version Code For UHIP Patients, email your UHIP card to email@example.com
Please be advised that not ALL reasons for visit can be treated over the phone. Therefore, under certain circumstances, the patient will be sent to a local clinic. For any concerns, please call 1-855-414-2255 for more information
Please List any drug allergies. If no allergies, please state “NONE” in the field.
Please Provide a List of Medications that you are currently taking. If no, please state “NONE” as your answer
Please Include Pharmacy Name, Address, Phone and Fax Number (Not required for patients who are requesting a COVID-19 assessment or testing)
If you do not have a family physician, type 'N/A'.
Only required for patients who are requesting a COVID-19 assessment or testing.
BY SUBMITTING THIS MEDICAL INTAKE FORM, I AM ACKNOWLEDGING THAT ALL THE INFORMATION IS TRUE AND
CORRECT TO THE BEST OF MY KNOWLEDGE. IN ADDITION, BY SIGNING THIS FORM, I CONSENT TO RECEIVING A
CALL FROM THE PHYSICIAN TO PROVIDE MEDICAL ADVICE OVER THE PHONE.