Please note that this form is for requesting appointments only. Availability will vary and someone from our office will call you to confirm your appointment request. Please do not submit any Protected Health Information.

Time of day you prefer

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Day of the week you prefer


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Full Name(*)
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Email(*)
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Phone(*)
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How did you hear about us?




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Referred by Doctor?
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Referred by ?
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Referred by other ?
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Describe nature of appointment

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I am aware that the services rendered are not covered by OHIP and that the clinic is not able to bill to my private insurance company directly. (*)
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Toronto Office

781 The Queensway, Unit N
Toronto, ON M8Z 1N4
Phone : (416) 253-6400
Mon
: 9:30am - 5:30pm
Tue
: 9:30am - 5:30pm
Wed
: 1:30pm - 7:30pm
Thu
: 9:30am - 5:30pm
Fri
: Closed

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