Please fill in the form below to setup an appointment.

Doctor

Reason for Appointment*

Please provide a reason for your appointment. Details are stored securely and not sent by email.

Patient Type*

Please let us know if you are a new or existing patient.

If you are a new patient, please fill out the following intake form:

PERSONAL DEMOGRAPHICS

Legal Name*

First Last

Preferred Name (if different than above)

First

This is the name that you identify with. Providing this allows our team to address you appropriately.

Date of Birth*

What are your preferred pronouns? (select all that apply)

Preferred Phone*

Type*

Secondary Phone

Type

Email Address

Preferred Method of Communication*

Address

Street Address Address Line 2 City Province Postal Code

HEALTH CARD (OHIP) INFORMATION

We verify the eligibility of any OHIP eligible patients ahead of their appointments, if applicable.

10 Digit Number*

2 Letter Version Code*

Expiry Date*

Best Time to be Reached for Confirmation (select all that apply)*

Preferred day of the week for your appointment (select all that apply):*

Preferred time of day for your appointment*

Comments

Phone

This field is for validation purposes and should be left unchanged.