Keele Family Practice

Keele Medical Appointment Form

Fill out the form below, and we’ll get back to you shortly with updates and to schedule your visit. Appointments are handled on a first-come, first-served basis.

Sick Note (there is $50 fee + tax)Health Problem

Name*

PrefixFirst NameMiddle NameLast Name

Date of Birth*

DayMonthYear

Gender*

YesNo

Ontario Health Card Number*

Invalid number won't be processed

Version Code*

Please enter the letters after your OHIP#

Phone Number*

Email*

example@gmail.com

Address*

Street Address

Street Address Line 2

CityProvince

Postal Code

YesNo

Please provide the list of your allergies below*

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.

Would you like to send us a photo or file to study before our visit?

YesNo

Virtual Health Appointment Non-Refundable Fee

Appointment Fee

If you have Ontario Health Card, this service is free for you, please simply return to "Ontario Health Card Number" , select "Yes" and enter the information. The service fee is non-refundable

$50.00CAD

Subtotal

$0.00CAD

Tax

$0.00CAD

Total

$0.00CAD

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