50 Westmount Rd
N Waterloo, ON N2L 2R5
P: 519-954-0111 | F: 519-954-0112
Hours: Mon - Fri: 10am - 5pm Sat - Sun: CLOSED (CURRENTLY CLOSED DUE TO COVID-19)
170 University Ave. W
Waterloo, ON, N2L 3E9
University Shops Plaza
P: 519-725-1514 | F: 519-725-5137
100 The Boardwalk
Kitchener ON, N2N 0B4
P: 519-279-4098 | F: 519-279-4099
*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.
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.