Online Doctor Appointment Form

Appointment Booking Form Halton Medix

Fill the form below and we will get back to you to confirm your appointment.
Name*

First Name Last Name
Phone Number*

Area Code Phone Number
Date of Birth*

Day Month Year
E-mail Address*
Have you been to our clinic before?*

YesNo
Reason for visit?*
Physician*
Appointment Location*

BurlingtonMilton
Please Note:

Staff will call you to confirm the availabilty of Doctor based on their schedule (Time and Location)
Appointment*
Disclaimer*

I undertand this appointment request is not confirm until I recieve a confirmation call or email from the staff.
Should be Empty:

Appointment Booking Form Halton Medix