Patient Appointment Booking

By checking these boxes, I give my consent to use the clinic’s online booking system.

I acknowledge that booking appointments online may involve some privacy and security risks.

I consent to the use of my personal and medical information for scheduling, managing, and confirming appointments.

I understand that the clinic will take reasonable steps to protect my information in accordance with PHIPA.

First Name

Middle Name

Last Name

Date of Birth

Patient Age

Patient Gender

Phone no.

Address

Address Line 1

Address Line 2

City

Province

Postal Code

Country

If you dont have a Government Issued Healthcard Kindly select Non - OHIP Patient

Non- OHIP Patient

OHIP Patient

Health Card Province:

Health Card Number:

Version Code (For Ontario OHIP, 2 Letters, required if applicable ) :

Expiry Date (Health Card)

Do you have a Family Health Doctor?

Yes