Keele Family Practice

Same Day Doctor Appointment Form

Fill the form below and we will get back soon to you for more updates and plan your appointment.
in this appointment for a Sick Note request or a Health Problem?*

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

Name*

PrefixFirst NameMiddle NameLast Name
Date of Birth*

DayMonthYear
Gender*
Do you have a valid Canadian Health Card?*

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

Cancelof
Receive text reminders for your appointment?*

YesNo

Virtual Health Appointment Non-Refundable Fee

Appointment FeeIf 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

Should be Empty:

Same Day Doctor Appointment Form