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.

in this appointment for a Sick Note request or a Health Problem?

Name

PrefixFirst NameMiddle NameLast Name

Date of Birth

DayMonthYear

Gender

Do you have a valid Ontario Health Card?

Ontario Health Card Number

Invalid number won't be processed

Version Code

Please enter the letters after your OHIP#

Phone Number

Format: (000) 000-0000.

Email

example@gmail.com

Address

Street Address

Street Address Line 2

CityProvince

Postal Code

Do you have any allergies?

Please provide the list of your allergies below

Do you use any medications?

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?

Receive text reminders for your appointment?

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

$50.00 CAD

Subtotal

Tax

Total

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year