Confirm Your Appointment

Please call (613) 233-303o to find out about advertising opportunities.

Your Full Name
Your Telephone number
Your appointment date
Date Format: MM slash DD slash YYYY
Time

: HH

MM
If you have difficulties with stairs or use a wheelchair or walker, please enter "YES" below
Do you have OHIP coverage?
Who is your family doctor?
Do you consent to receiving notifications by text messaging from our office?
If YES, please confirm your cell phone number
Your appointment will be confirmed after you complete and submit this form
* You will receive a reminder 2 weeks before your appointment
** If you wish to cancel or change your appointment please call (613) 233-3030
Name
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