Appointment Request
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Personal Information
First Name
Last Name
Email
Date of Birth
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Family Members
Would you like to book any additional family members?
No
Yes
Family Member 1
Full Name
Date of Birth
Add Another Family Member
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Preferred Appointment Time
First Available Appointment
Specific Date (choose below)
Any Weekday Morning
Any Weekday Afternoon
Any Monday Morning
Any Monday Afternoon
Any Tuesday Morning
Any Tuesday Afternoon
Any Wednesday Morning
Any Wednesday Afternoon
Any Thursday Morning
Any Thursday Afternoon
Any Friday Morning
Any Friday Afternoon
Please Choose Date
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Reason for Visit
Please describe the reason for your visit, including any concerns or symptoms.
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Are you a New or Existing Patient?
Select One
Existing Patient
New Patient
Address
Address
City
Province
Postal Code
Submit
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Additional Information
Preferred Name (Optional)
Health Card # and Version Code
Select Gender
Male
Female
Non-binary
Other
Prefer not to say
Gender
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Additional Information
Preferred Phone
Mobile
Home
Work
Alternate Phone (Optional)
Mobile
Home
Work
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