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See a Doctor 100% Covered By OHIP
We'll ask you a few questions to match you with a doctor. All your information is kept strictly confidential and 100% secure.
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1
What Is Your Name?
*
This field is required.
First Name
Last Name
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2
What Is Your Email Address?
*
This field is required.
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3
OHIP NUMBER
This allows us to offer your appointment for free. If you don't have this handy you can provide it before your appointment. *By requesting an appointment, you agree to Rocket Doctor’s
Terms and Conditions
,
Email Communications Policy
,
Informed Consent
, and
Privacy Policy
.
OHIP number
Expiration Date
Version Code
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4
What's Your Date of Birth?
*
This field is required.
-
Date
Month
Day
Year
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5
What's your gender?
*
This field is required.
Male
Female
Non-Binary
Male
Female
Non-Binary
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6
Address
*
This field is required.
Street Address
Street Address Line 2
City
State/Province
Postal/Zip Code
Canada
Canada
Canada
Country
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7
Phone Number
*
This field is required.
Area Code
Phone Number
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8
What's the main reason that you want to see a doctor?
*
This field is required.
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9
Placeholder Email
example@example.com
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10
utm_medium
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11
utm_source
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12
utm_campaign
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13
Tags
Todo
In Progress
Done
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