Patient Intake Forms

Referral Form for Healthcare Providers

Patient Intake Forms

To receive free (OHIP covered) consultation you are required to fill out mandatory Patient Intake Forms EACH TIME prior to your consultation. Fill out these forms only after your initial appointment booking. If these forms are not completed in time, we may not be able to process your booking.

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

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

First Time Patients

1. Mandatory Form

2. Mandatory Form

Follow-up Patients

1. Mandatory Form

Get a referral

We kindly ask you to get a referral from your Family Doctor, Pediatrician or Midwife to our co-operating clinic Quick Care Pediatrics. Referral fax is: +1-519-512-0051. Bellow is a short referral form to be filled out by your healthcare provider.