Name:

Address:

Phone:

Email:

Date of Birth (dd/MMM/yyyy):

OHIP# (10 Digits+2 Letter Version Code ):

Have you been to our clinic before?

Yes
No
Not Sure

Type of Consultation:

On-Site Clinic Consultation
Telephone/Virtual Consultation
No Preference

Doctor Preference:

Female Doctor
Male Doctor
No Preference

Preferred Date, Time, and Reasons for visiting doctor: