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Open 1:00pm ET / 12pm CT to 9:00pm ET / 8:00pm CT 7 Days a Week
Register for a virtual appointment here
Register for a virtual appointment here
Open 1:00pm ET / 12pm CT to 9:00pm ET / 8:00pm CT 7 Days a Week
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Book your appointment online
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Returning Patient
Opt Out Of The Video Call For This Visit?
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First Name
Last Name
Gender
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Female
Other
Date of Birth
Age
Blood Type
Select a blood type
Blood group A
Blood group AB
Blood group B
Blood group O
Unknown
Email
Phone Number
Address
City
Province
Postal Code
Do you have a regular family doctor?
Yes
No
If yes
Health Card Number
History
Medical Problems
Yes
No
If yes
Medications
Yes
No
If yes
allergies
Yes
No
If yes
Preferred Pharmacy
Yes
No
If yes
Have you contacted your family doctor?
Yes
No
If yes
Referred by 811?
Yes
No
Do you have any of the following?
Cough
Yes
No
Fever 38 or Greater
Yes
No
Shortness of Breath or Chest Discomfort
Yes
No
Runny Nose
Yes
No
Vomiting
Yes
No
Diarrhea
Yes
No
abdominal
Yes
No
Rash
Yes
No
Eye Discharge
Yes
No
Travel in last 14 days
Yes
No
Do you smoke?
Yes
No
Contact with person diagnosed with COVID-19 or other communicable disease in the last 14 days
Yes
No
Have you been discharged from hospital in the last 14 days?
Yes
No
If you answered yes to any of the questions above, please describe
Main reason for medical visit request today
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