Test bug Gform

Appointment Form – English

"*" indicates required fields

Name of doctor who referred you

Department you are being referred to (if known)

Attach a referral*

Accepted file types: jpg, png, pdf, doc, jpeg, Max. file size: 5 MB.

IMPORTANT: Ensure your file is under 5MB before uploading to avoid errors or rejection. If it exceeds the limit, compress or reduce its resolution. Please make sure that your attachment is clear and legible. We do not process incomplete applications or provide appointments without a copy of the referral. If you do not attach your referral, you will need to fax it to the department directly. Wait times depend on the priority assigned to the referral and can be as long as several months.

Patient Information

Child's last name*

Child's first name*

Date of birth*

MCH Medical record number (if known)

Health insurance card number*

Health insurance card expiration date*

‘DD’ corresponds to the child’s date of birth.

Address*

Select your province or territory*

City*

Postal code*

Contact Information (for parent or guardian)

Your first name*

Your last name*

Your relationship to patient*

Email address

Phone number*

Alternate phone number

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