Request an appointment

If you know the name of the clinic, please consult the Clinics Directory. If you don’t know the name of the clinic, please fill out the form below.

Clinics Directory

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: 2 MB.

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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