OFHC - Appointment Request Form

Have you seen our provider before *

My family doctor is *

First Name *

Last Name *

Phone

Format: 416-439-0163

Date of Birth *

e.g. 11/14/1971

Gender *

Email *

Valid email is required e.g. email@mail.ca

Number *

1234

Street *

Any Street

City *

Scarborough

Postal Code *

X9X 9X9

Province *

OHIP Card Number *

e.g. 4505555999

Version *

e.g. AA

Issue Date *

e.g. 12/31/2000

Expiry Date *

e.g. 12/31/2020

Select Appointment Type:

Virtual (Telephone) Visit

This is a telephone visit with your doctor. Once the appointment is accepted you will be informed via email.

Virtual (Video) Visit

This is a video visit with your doctor. The doctor will review the request to determine if an in-person visit is required or if it could even be resolved via telephone visit. Once the appointment is accepted you will be informed via email.

In-person Visit

This is an in person visit with your doctor. The doctor will review the request to determine if an in-person visit is required or if it could even be via a telephone or video visit. Once the appointment is accepted you will be informed via email.

Preferred appointment days:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Preferred appointment time: *

Select reaon for this appointment: *

I have read and accept the Clinic Policies

By checking this box:

I consent to communicate and have care provided care using virtual and other telecommunications tools. I understand the risks related to unauthorized disclosure or interception of personal health information and steps I can take to help protect my information. I understand that care provided through video or audio communication cannot replace the need for physical examination or an in person visit for some disorders or urgent problems and understand the need to seek urgent care in an Emergency Department as necessary.

I agree that I have been advised that I do not need to attend clinic to see a Doctor in person due to the COVID-19 pandemic. I understand that I should stay home and practice social distancing. I understand that I should only attend clinic for urgent matters. For example, if I have fever, cough, shortness of breath, I understand that I should call telehealth or my healthcare provider to advise me how to proceed.

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