All submitted information must pertain exclusively to a single patient. Please observe the following directions for using this form.
1) Do not input personal information for anyone other than the patient who is sending documents or requesting an appointment. (i.e. yourself or a dependent)
2) Do not submit information or request an appointment for multiple family members at one time. Instead, you should submit one complete form for each patient individually to avoid confusion regarding the request or information. (ex: Submit the form 3 times for 3 children needing an appointment, each with child specific information such as health card #, legal name, and date of birth, as well as pictures or descriptions relating to that individual case).
Also, please note that this form does not work with older browsers such as Internet Explorer. If you are experiencing difficulties with form submission, please try using Google Chrome, Firefox, or Microsoft Edge instead. Some older mobile devices may not be compatible with this form as well.