First Name *Last NameEmail Address *Telephone NumberDate Of Birth *Street AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeType of Patient *Type of PatientFamilyWalk InAppointment Type *Appointment TypeUrgentRoutineAppointment Reason: Due to scheduling constraints, we kindly ask patients to limit their appointment to addressing one issue per visit. Thank you for your understanding.OHIP Number: *Expiring date: *Version Code *Do you have a Family Doctor ? *Do you have a Family Doctor ?YesNoWhat City is your Family Doctor ? * Consent *I understand that I am submitting a REQUEST for an appointment with Barrie Harmony Clinic. I agree to be notified about confirmation for my appointment via email, telephone, or SMS. I am responsible for attending my appointment if confirmedSUBMIT REQUEST
