Fill out the information below, or call:
1-855-414-2255.

*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.