First time visitor must fill in this form.
Our clinic staff member will call you to set your appointment.

Returning visitor must call +1 (705) 503-5300 to speak
with office administrator to set an appointment.

Your Name*

Your Email*

Phone Number*

Address *

Date of Birth*

Health Card*

Past History*

Current Medications*

Allergies *

Family History *

Hospitalizations*

Smoker*
YesNo

Alcohol Use *
YesNo

Additional Comments