Patient Intake Form

1. For newborn discharged from the hospital, please BRING with you all baby’s discharged papers from the hospital on your first appointment.

2. For all other children, a referral letter from your family doctor is needed to register at the clinic.

3 For urgent care issues, the clinic is open for walk-in same day appointments subjected to how the clinic is busy and the pediatrician’s availability.

Name

First Name

Last Name

Birth Date

MM

DD

YYYY

Sex

OHIP Health Card & Version Code

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

Phone

(###)

###

####

Alt. Phone

(###)

###

####

Please type your child's medical concern?

Does your child has a family doctor?

Yes, a referral from your family doctor is needed.

No, the first appointment will be scheduled to see a pediatrician who may need a referral letter after the first appointment.