Rapid Access Check In (HOME)

1

What Is Your Current Location?* This field is required.

Not At The Clinic (Home)

At The Clinic (Reception Desk Or Parking Lot Etc.)

2

Have You (Patient) Used Our Facility In The Last 2 Years?* This field is required.

YESNO

3

Did You See A Doctor In-Person At Our Clinic Or Was It Strictly Telemedicine?* This field is required.

In-person & Telemedicine

Telemedicine Only

4

Do You Have A Health Card From Ontario?* This field is required.

YESNO

5

Choose The Category That Best Fits Your Situation.

I Have Health Card From Another Province In Canada (Out Of Province Patient).

Health Card From Quebec.

I Do Not Have A Health Card - Refugee Status.

Out of Country Patient / No health Card / Visitor / Student.

(Lost, Stolen, Expired) Invalid Health Card.

Other.

6

Please Provide Your 10-Digit Health Card Number And 2-Letter Version CodeEx. 1234567890-AB

7

Provide Patient Full Name.* This field is required.

First Name

Last Name

8

What Is Your Age (In Years)?Ex., 23

9

Cellphone Number.* This field is required.To receive SMS and calls from clinic

Please enter a valid phone number.

10

City You Currently Live In.* This field is required.Ex. Mississauga, Toronto, Brampton, Oakville etc.

11

What Is Your Symptom/Medical Reason For The Visit?* This field is required.

12

As Of Dec 1st, 2022, Telephone Medicine Services Have Been Severely Limited By OHIP. Are You Able To Come In-Person To See A Doctor?* This field is required.

YESNO

13

Great! We Are Open 8am-11pm 365 Days A Year (Including Holidays).

Feel Free To Walk-in Anytime To Meet With A Doctor Or Medical Specialists.

For More Info, Visit Www.rapidaccess.ca Or Text Our Hotline At 1 (855) 629-0365

See You Soon!

14

Based On Availability, Our Doctors May Be Able To Provide Limited Telemedicine Services To Some Patients. As A Part Of This Visit, You May Be Asked To Come In-person For A Physical Assessment Or Specialist Consultation (If Applicable). Are You Willing To Come In-person If It Is Required?

Yes, I Will Come In-Person If Required.

No, I Will Never Be Able To Come In-Person To The Clinic.

15

Please Provide The Reason You Are Unable Visit The Clinic In-Person.* This field is required.