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? *

Yes No
Reason for visit? *
Physician *
Appointment Location *

Burlington Milton
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