TRIAGE FORM for Dr. Anh Tran's Rostered Patients

TRIAGE FORM for Dr. Anh Tran's Rostered Patients
HOLIDAY CLINIC HOURS

Our clinic will have adjusted hours during the holiday season:

In-person appointments
Closed: Friday, December 20, 2024, to Friday, January 3, 2025
Resuming: Monday, January 6, 2025

Phone appointments
Available on:

Tuesday, December 24
Friday, December 27
Tuesday, December 31
Thursday, January 2

We wish you a safe, healthy, and joyful holiday season!

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IN-PERSON APPOINTMENTS:

- Tuesday, Thursday every week; 1 Saturday every month

TELEPHONE APPOINTMENTS:

- Monday, Tuesday, Thursday and Friday

Telephone consults can only be booked for when you are in Ontario. Dr. Tran is NOT available outside of clinic hours, SUNDAY, and STAT holidays. Due to the high volume of phone call requests daily, your request will be answered according to the triage protocol within 5 clinic days.

If this is an urgent or emergent medical issue, please go to the nearest Emergency Department.

Anh Ngoc Thi Tran, MD, CCFP
T&T Medical Clinic
3175 Rutherford Rd #26
Building F, L4K-5Y6
Concord, ON, CA
Phone: 905-761-5482
Fax: 905-761-0523
Current Date & Time

MonthDayYear
DateHourMinutesAM/PM Option
Name*

First NameLast Name
Email or Phone Number*
Please indicate all the symptoms you have experienced recently.

FeverCoughShortness of BreathTirednessSore ThroatAches & PainsStuffy noseRunny noseDiarrheaHeadacheAbdominal painLoss of smellLoss of tasteLoss of appetiteNauseaVomitingChillsOther
I would like to speak with Dr. Tran about:*

MY TEST RESULTSMY HEALTH ISSUESMY IMMUNIZATION & PREVENTATIVE CAREMY MEDICATIONSOTHER GENERAL MEDICAL QUESTIONS RELATING TO ME
IF YOU HAVE ANY DOCUMENTS OR IMAGES TO SUBMIT TO DR. TRAN, PLEASE INDICATE BELOW. A LINK TO UPLOAD THE DOCUMENT WILL BE EMAILED TO YOU.
When is the best time for Dr. Tran to call you within the next 5 clinic days?*

ANYTIMEOther
I would like to book*

A PHONE APPOINTMENTAN IN-PERSON APPOINTMENTBOTH PHONE AND IN-PERSON APPOINTMENTS
Please check off after you review this statement*

IF I DO NOT HEAR FROM DR TRAN WITHIN 5 DAYS AFTER SUBMITTING THIS FORM, I WILL CONTACT DR. TRAN'S OFFICE. I am aware that I can only book an appointment when I am currently in Ontario. I am aware that I can complete this online booking form any time and I will receive a phone call from Dr. Tran within her clinic hours according to the triage protocol. I am aware that if I want an in-person appointment, I can book online or by leaving a voicemail message at her office by calling 905-761-5482. I am aware that Dr. Tran is available for both telephone or in-person assessments. I consent to communicate with Dr. Tran and receive care using virtual and other telecommunication tools. I am aware of the risks related to unauthorized disclosure or interception of personal health information when use virtual or telecommunications tools. I will discuss with Dr. Tran regarding steps that I can take to help protect my online information. I understand that the care provided through video or audio communication cannot replace the need for physical examination or an in person visit for some disorders or urgent problems. I understand the need to seek urgent care in an Emergency Department as necessary.
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