PA Booking

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Please fill out the intake form below

All your information is kept strictly confidential and 100% secure. For life-threatening emergencies call 911. If you are suffering an acute mental health crisis call 1-833-456-4566.
This appointment is for myselfThis appointment is for my dependent
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Patient Information
Patient name*

First NameLast Name
Pronouns
Please select "Other" to provide the patient's preferred pronouns
Please enter the preferred pronouns
Date of birth*

MonthDayYear
Date
Sex assigned at birth*
Gender identity
Please select "Other" to provide the patient's preferred gender identity
Please enter the preferred gender identity
Email address*
example@example.com
Phone number*
Please enter a valid phone number.Format: +1 (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code

Caregiver/Guardian Information
What is your name?*

First NameLast Name
Pronouns
Please select "Other" to provide your preferred pronouns
Please enter your preferred pronouns
Date of birth*

MonthDayYear
Date
Email address*
example@example.com
Same phone number as my dependentEnter new phone number
Please enter your phone number*
Please enter a valid phone number.Format: +1 (000) 000-0000.
Same address as my dependentEnter new address
Please enter your address*

Street Address

Street Address Line 2

CityProvince

Postal Code

What is the main reason you want to see a Physician Assistant?*
" If you are experiencing severe chest pain or shortness of breath, please call 911 and/or go immediately to the nearest emergency department. "
What is the main reason your dependent want to see a Physician Assistant?*
Please select one of the following medications for a prescription refill.*
If you don't see your medication, please select "Other" to type out the name of your medication.
Please select one of the following:*
If you don't see your option, please select "Other" and describe in the tell us more section below.
Please type out the name of your medication(s).
Please type out the name of your dependent's medication(s).
If you have a preferred pharmacy, please enter the pharmacy name.
Please enter the fax number of your preferred pharmacy.
Please enter a valid phone number.Format: +1 (000) 000-0000.
Tell us more. Please describe the details for your visit.*
Tell us more. Please describe the details for your dependent's visit.*
YesNo
Please enter your Blue Cross ID*

My Products

Live Video Call with a Physician Assistant

Connect with a qualified Physician Assistant through live video call from your smart phone, tablet or computer.

$65.00CAD

Total

$0.00CAD

*By requesting an appointment, you agree to Rocket Doctor’s Terms and Conditions, Email Communications Policy, Informed Consent, and Privacy Policy.
Please note that you may not necessarily be booked for the exact date / time shown on the previous page.Your reason for booking and the clinical context of the next available physician will determine the exact appointment details. Refunds will not be issued where appointments do not align with the selected time, although we will do our best to work with your schedule.

No Show Policy: If you book an appointment and fail to appear with less than 24hrs notice, Rocket Doctor reserves the right to charge a No Show fee equal to the full cost of the appointment.

Cancellation Policy: If you book an appointment and cancel with less than 24 hours notice Rocket Doctor reserves the right to charge a cancellation fee equal to the full cost of the appointment. If you fail to book an appointment or cancel with more than 24 hours notice, Rocket Doctor will withhold an administrative fee of $5.00 from your refund.
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