Southeastern Ontario Health Sciences Centre
Request for NON URGENT Clinic Appointment

All appointments will be booked in the NEXT AVAILABLE time slot. Patients will be notified by mail. A referring letter and X-Ray report must be sent to the Attending Physician's Office

Please fill out the below information and click the Print button to generate the form.

Today's Date:
CR Number:   Date of Birth:
Last Name:   Address:
First Name:   Apartment:
Middle Initial:   City:
Maiden/Other Names:   Postal Code:
Marital Status:   Phone:
Health Insurance:   Business:
Version Code:
Service Information
Other Insurance:
(e.g. FPS Inmate #)
Family Physician:
Reason for Referral:
Sports Related:  
X-Ray/Diagnostic Inquiries:  
X-Ray/Diagnostic Location:   Date:
Specific Physician requested:
Service Referring to:
Referring Physician Information
Referring Physician:
Office Phone Number:   Fax Number: