Payment

PATIENT INFORMATION
Patient's Name (same as OHIP card)*
First Middle Last
Patient's Date of Birth*
MM slash DD slash YYYY
Patient's email*
Patient's Address*
Street Address Address Line 2 City Province Postal Code
Patient's Main Contact Phone Number*
Is the billing information same as patient?*
- Yes
- No
What is your name?*
First Middle Last
What is your address?*
Street Address Address Line 2 City Province Postal Code
What is your main contact phone number?*
APPOINTMENT INFORMATION
Date of the appointment*
MM slash DD slash YYYY
Physician's Name
First Last
Payment
Select the service or document required for payment:*
Please ensure to select the correct type of note or the correct service. If the type of note you select does not match what you have requested from the doctor, you will not receive the document and a refund will be issued.
Credit Card*
Card Details
Cardholder Name

PATIENT INFORMATION