IMPORTANT: If your child has a medical emergency do not use this form. In case of an emergency, contact your family physician or go to the nearest CLSC or Emergency.
Please complete the form below to request an appointment. One of our staff members will contact you within three (3) business days to confirm your appointment date and time.
You may also contact us by phone by consulting our service list
This online appointment request is secure and confidential.
DO NOT USE THIS FORM IF THE SPECIALTY YOU NEED IS NOT INDICATED ON THE LIST. DO NOT USE THIS FORM IF YOU ARE LOOKING FOR A PEDIATRICIAN, GO TO WWW.PEDIATRES.CA.
* Indicates required field
*Name of doctor who referred you to The MCH
*Briefly describe the reason for this appointment(as indicated on the referral)
*Medical specialty or clinic name for your appointment Select a Specialty Adolescent Medicine Allergy / Immunology Asthma Cardiology Cleft Palate Dentistry Dermatology Dermatology – Molluscum Diabetic Endocrinology Gastroenterology (GI) General Pediatrics (Pediatric Consultation Centre – PCC) General Surgery Gynecology Infectious Diseases Neonatal Follow-up Nephrology Neurology Neurosurgery Ophthalmology Orthopedics Otolaryngology (ENT) Plastic Surgery Respiratory Medicine Rheumatology Urology
Name of doctor you were referred to (if applicable) Select a Physician
Is this your first visit to The MCH ? yes no
*Is this your first visit to this clinic ? yes no
*Child's last name
*Child's first name
*Date of birth Format : YYYY/MM/DD
*Age
MCH Medical Record number (if known)(upper right corner of MCH red hospital card)
Address (street)
City
Province
Postal Code
*Home phone number
*Your last name
*Your first name
*Your relationship to patient
*Daytime phone number Ext.
*Alternate phone number Ext.
Email address