Standard Appointment Request

This is our standard appointment request form.  If you prefer to create, or login, to your online account to manage your appointments please use this page: Online Log-In or Account Creation

 

Have you been to our clinic before?
Do you have a Doctor you would like to request?
If so, which Doctor?
When would you like an appointment?
First Name (as printed on valid Health card)
Last Name (as printed on valid Health card)
Birth Date:
Gender:
Address:
City:
Postal Code:
Phone Number(s):
Email:
MHSC Number (6 digits)
PHIN Number (9 digits)
Reason for Visit (optional)