Women's Clinic | Women Health Care

Answer the following questions so the doctor can better help you.

Why are you booking a virtual visit? *

What's your reason for seeing a psychiatrist? *

What's your reason for seeing a gynecologist? *

What's your reason for seeing a dermatologist? *

What's your reason for seeing a pediatrician? *

What's your reason for seeing a general internist? *

What's your reason for seeing a nephrologist? *

What's your reason for seeing a cannabis consultant? *

Answer the following questions so the doctor can better help you.

What is the name of the medication you need? *

Why do you need this medication? *

Are you currently on this medication? *

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If yes, how long have you been taking it? *

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Answer the following questions so the doctor can better help you.

For which specialist do you need a referral? *

Answer the following questions so the doctor can better help you.

What's your reason for seeing a psychiatrist? *

What's your reason for seeing a gynecologist? *

What's your reason for seeing a dermatologist? *

What's your reason for seeing a pediatrician? *

What's your reason for seeing a general internist? *

What's your reason for seeing a nephrologist? *

What's your reason for seeing a cannabis consultant? *

Answer the following questions so the doctor can better help you.

Please describe what you are experiencing. *

How long has this been an issue? *

Not Applicable

What is the frequency, intensity, and duration? *

Not Applicable

What makes it better or worse? *

Not Applicable

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Personal Info

Your Full Name *

Date of Birth *

Sex *

Contact Info

Cell Number *

Home Number

Email *

Address *

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Province *

Postal Code *

Please select your health coverage.

Card Number

Issue

Expiry

Non-Ontario Health Card

Province

Card Number

Issue

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Students

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Family Doctor (Optional)

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Fax Number

Address

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Province *

Emergency Contact

First Name *

Last Name *

Relationship *

Cell Number *

Email *

Home Number

Provide some additional registration to save time

Current/Past Medications *

Not Applicable

Major Hospitalizations, Illnesses, Surgical Procedures *

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Allergies *

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Select your preferred pharmacy using one of the following options so we know where to send your prescriptions.

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Pharmacy Name *

Pharmacy Address *

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Review the following information to ensure they are correct.

Scheduled Appointment Edit

Appointment Date:

Friday, Oct 30, 2020

Appontment Time:

9 - 10am

Reason for Visit Edit

Service Type:

Test Type:

Specialist

Issue

Reason for booking:

Description of symptoms:

How long has this been an issue?

What is the frequency, intensity, and duration?

What makes it better or worse?

Name of medication needed:

Why do you need this medication?

Currently on this medication?

How long have you been taking it?

Preferred Lab Edit

Lab Name:

Address:

Telephone:

Fax Number:

Personal Info Edit

Full Name:

Home:

Birthday:

Cell:

Gender:

Email:

Address:

Health Coverage Edit

Card Type:

Attached File:

Card Number:

Issue Date:

Expiry Date:

Family Doctor Edit

Doctor's Name:

Cell:

Address:

Fax:

Not Entered

Emergency Contact Edit

Full Name:

Relationship:

Cell:

Email:

Medical History Edit

Current Past Med:

Major Hospitalizations, Illness, Surgical Procedures:

Allergies:

Preferred Pharmacy Edit

Pharmacy Name:

Address:

Telephone:

Fax Number:

Womens Health

How It Works

Need to speak to a Gynecologist?

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Book an Appointment

Speak to a Gynecologist

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Other Specialists

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