Appointment Request Form
(Only use this form to request, cancel or reschedule a regular appointment with our Family Physicians)
1. Personal Information
Patient Name (First & Last):
*
Date of Birth
*
-
Day
-
Month
Year
Date
Health Card Number:
*
Add province eg (AB 12345-1234)
Contact Number:
*
Format: 4031231234
2. Your Request
Type of request
*
New Appointment (Meet & Greet)
New Consultation Appointment
Follow-up (eg. Prescription Refill, Results, etc)
Cancel or Reschedule Appointment
Other
Physician:
Please Select
Dr Ahmed Enbya (Accepting New Patients - Male)
Dr Sidra Feroz (Accepting New Patients - Female)
Dr Radheya Abuaziza (Accepting New Patients - Female)
Dr Aous Al-Shihabi
Dr Elhadi Mohammed
Dr Hatim Kheir
Dr Mewhish Hanif
Dr May Aldabbagh
Dr Nour Bukhres
Dr Oladuton Oyediran
Dr Sandeep Kumar
Dr Thomas Nel
Comments (optional)
eg I would like to request a Meet & Greet appointment for a family of 5
Disclaimer
Health Plus Medical Clinic (HPM) is committed to protecting the privacy, security, and confidentiality of all personal health information submitted on this form. Information provided is used solely to facilitate your booking request. Only authorized clinic personnel who require access to this information to perform their duties will review, use, or process it. All personal health information is handled in accordance with Alberta’s Health Information Act (HIA) and Health Plus Medical (HPM’s) internal privacy and confidentiality policies. Your information will remain confidential and will not be shared outside the clinic unless required by law. Identifying details may be removed when used for training or internal reporting. For any privacy-related questions or concerns, contact our Clinic Manager or Privacy Officer at manager@healthplusmed.ca
Submit
Should be Empty: