To book an appointment please fill out the form below and we will contact you with an appointment within 48-72 hours.

Patient Last Name:

*

Patient First Name:

*

Primary Contact Phone Number:

*

Contact Name:

*

Destination:

*

Departure date:

*

Date of Birth:

*

Gender:

Select No Preference Male Female *

Email:

*

Health card number:

*

Preferred time:

8:00am - 12:00pm 12:00pm - 4:00pm 4:00pm - 8:00pm

Preferred day:

Weekday Weekend

Are you Pregnant?

Yes No

Choose a Location:

Any Location 150 Katimavik Rd. 1582 Bank St. 2016 Ogilvie Rd. 225 Preston St. 2573 Baseline Rd. 368 Slater St. 900 Greenbank Road *

I live in:

Ottawa Quebec

Please type:

*

If the text in the image is not entered correctly, you will be required to re-fill the form.