Pediatric | Pediatric Toronto

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? *

Yes No

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

Not Applicable

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

What kind of test are you looking for? *

Describe your reason for booking in detail. *

Select your preferred LifeLabs location so we know where to send the lab requisition.

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Preferred Lab

Lab Name *

Lab Address *

City *

Province *

Postal Code *

Phone Number

Fax Number

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

Attach photo(s) of the area of concern *

Not Applicable

Include pictures with different angles and details to clearly show the area of concern. Please ensure they are not blurry and have good lighting. You can upload a maximum of 3 photos that are at least 300px wide or tall (we recommend at least 1000px).

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The doctor will call you within your chosen time frame.

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Select the time *

Morning

Afternoon

Evening

Morning

Afternoon

Evening

Provide your information so a doctor can contact you.

Personal Info

Your Full Name *

Date of Birth *

Sex *

Contact Info

Cell Number *

Home Number

Email *

Address *

City *

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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If you do not have a UHIP or IFHP, you may skip to the next page, however there will be costs associated with eachservice. Learn more.

Provide some additional registration to save time!

Family Doctor (Optional)

Doctor's Name

Phone Number

Fax Number

Address

City

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 *

Not Applicable

Allergies *

Not Applicable

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

Search by typing in your pharmacy name and its street or address

Telephone:

Looking for pharmacies near you

Preferred Pharmacy

Pharmacy Name *

Pharmacy Address *

City *

Province *

Postal Code *

Phone Number

Fax Number

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:

Pediatric & Adolescent Care

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