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.

For First Time Patients

Fill out the following forms immediately after your initial booking:

1. Registration Form

2. Initial Visit Form

For Follow-up Patients

Fill out the the following form no earlier than a day before your visit:

1. Follow-Up Form

Get a Referral

A referral is required for your initial appointment booking. Please get a referral from your Family Doctor, Pediatrician or Midwife. Referral must be issued to your baby's name and addressed to our co-operating clinic Quick Care Pediatrics. Bellow is our short referral form, please share it with your healthcare provider.

Our referral fax is: (519) 512-0051.

Referral Form for Healthcare Providers

You can also get a free online referral by visiting a virtual Walk-In Clinic here: MD Connected.