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Rapid Access Clinic - Online Check-In
Fill in the form to check-in and get a room number for meeting with the doctor
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1
What Is Your Current Location?
*
This field is required.
Not At The Clinic (Home)
At The Clinic (Reception Desk Or Parking Lot Etc.)
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2
Have you (patient) been to our clinic as a patient in the last 12 months?
*
This field is required.
Yes
No
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3
In 5 words or less, please describe your symptom/medical reason for your visit today.
*
This field is required.
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4
Choose the province that you have a health card with.
*
This field is required.
Ontario
No Health Card (Refugee, Out Of Country, Cash Pts)
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Prince Edward Island
Quebec
Saskatchewan
Yukon
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5
Select patient type.
*
This field is required.
Refugee
Visitor/Out of Country Patient
Other
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6
Health Card #.
*
This field is required.
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7
Full legal name of the patient
*
This field is required.
First Name
Last Name
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8
Date of birth
*
This field is required.
For Ex: 23 Apr 1995
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9
Birth Date
*
This field is required.
-
Month
Day
Year
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10
Birth Date
*
This field is required.
-
Month
Day
Year
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11
Sex:
*
This field is required.
Male
Female
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12
Cell Phone Number
*
This field is required.
Please make sure your cellphone is sufficiently charged & can receive incoming calls/Text Messages. DO NOT PUT '1' IN FRONT OF THE NUMBER
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13
Cell Phone Number
*
This field is required.
Please make sure your cellphone is sufficiently charged & can receive incoming calls. DO NOT PUT '1' IN FRONT OF THE NUMBER
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14
E-mail:
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