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