Dr. Laval Contact Form

1
This contact form is not intended for medical emergencies.

If this is a medical emergency, please do not use this form, call 911 immediately!
2
What is you name?* This field is required.
First Name
Last Name
3
What is your date of birth?* This field is required.Example - 1998-07-19
4
Gender* This field is required.
Please Select
Please Select
Female
Male
Nonbinary
Prefer to self-describe
Decline to state
5
Phone Number* This field is required.Please provide your phone number ( Canadian or US only )
Phone number
6
Email* This field is required.
example@example.com
7
Are you an existing patient of Dr. Laval?* This field is required.Answer yes if you have already had at least one in person or virtual care meeting with Dr. Laval. Otherwise, reply No.
Yes
No
8
When was your latest visit?* This field is required.
Last 7 days
Last 30 days
Last 3 months
More than 3 months ago
9
What clinic did you last visit?* This field is required.
Appletree - 2150 Robertson Road
PulsePoint - 2730 Iris Street
10
What would you like to contact Dr. Laval about?* This field is required.You will be able to provide additional information in the next step.
Very Brief Subject line
11
Provide more information relevant to your messageAny relevant information you would like to add goes in here.
Huge
Large
Normal
Small
Ok
Ok
12
Please verify that you are human* This field is required.
Should be Empty: