Patient Intake Forms

Patient Intake Forms

To receive free (OHIP covered) consultation you are required to fill out Patient Intake Form(s) EACH TIME prior to your consultation. Fill out these forms only after you have booked an appointment with us. If forms are not completed in a timely manner, we may not be able to process your booking.

Please take special care in providing correct Health Card Numbers as this information will be checked against the OHIP system.

Please note, forms will open in a new browser Tab. No additional confirmation emails will be sent to you after submitting the forms.

First Time Patient Forms

Please fill out these 2 forms immediately after your initial booking:

Follow-up Patient Form

Please fill out this form no earlier than a day before your follow-up visit:

Follow-up Medication Renewal Form

Fill out this form only as a follow-up patient and if you require your drug prescriptions to be refilled by a doctor:

Prenatal Patient Form

Fill out this form only as a prenatal patient:

*Get a Referral

A referral is required for your initial OHIP covered appointment booking.

Please get a referral from your Family Doctor, Pediatrician or Midwife. Referral must be issued to your baby's name and to be addressed to Ontario Breastfeeding Network. In case of multiples, each baby must have their own referral.

Example:

Patient: Baby's First Name, Last Name
Referred to: Ontario Breastfeeding Network
Referring Practitioner's OHIP billing Number: XXXXXX

*We reserve the right to refuse services because of an incorrectly issued referral.

 

 

 

Bellow is a short referral form (Online or Fax versions), please share it with your healthcare provider:

For your convenience, you can also obtain a free doctor's referral by visiting following virtual clinics here: