Care365 Family Practice

Appointment Form

Fill the form below and we will get back soon to you for more updates and plan your appointment.
Do you have a valid Ontario Health Card?*

YesNo ($50)
Non-resident appointment Fee
Do you need a Sick Note?*

Yes ($50)No
Sick Note Fee
Total
Appointment Form

Fill the form below and we will get back soon to you for more updates and plan your appointment.
Name*

PrefixFirst NameMiddle NameLast Name
Date of Birth*

DayMonthYear
Gender*
Ontario Health Card Number*
Invalid number won't be processed
Version Code*
Please enter the letters after your OHIP#
Phone Number*
Please enter a valid phone number.
Email*
example@gmail.com
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Do you have any allergies?*

YesNo
Please provide the list of your allergies below*
Do you use any medications?*

YesNo
Please list the names, strengths, and dosages of your medications, along with how you take them, in the space below.*
What is the primary reason for your visit to the doctor?*
Please explain as detailed as possible, explain if it is a refill request, what medication, what condition, etc.
Is there a specific medication you would like to request?*

YesNo
What is your requested medication name and dose?*
Do you have a preferred pharmacy for your prescriptions?*

YesNo
Pharmacy information

Please enter the phone number and fax number of the pharmacy below
Pharmacy Phone*
Please enter a valid phone number.
Pharmacy Fax*
Please enter a valid fax number.
Would you like to send us a photo or file to study before our visit?

Cancelof
Do you agree to receive text reminders for your appointment?*

YesNo

Care365 Appointment Payment Total

CADDescription

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Appointment Form

Pharmacy information