Downloadable Forms

  • Medical Record Transfer Request Form

    Download

  • Consent to Use Electronic Communications E-visit

    Download

Uninsured Services

What You Need To Know…

The Ontario Health Insurance Plan (OHIP) provides coverage for a vast majority of physician services: however, there are some services that are not covered. Our Physicians are pleased to offer these valuable services; however, the responsibility for payment lies with the patient or the third party requesting the service. Quality health care, medical advice and timely access are priorities that Ontario’s physicians intent to honour, that are not covered by OHIP

    • Missed appointment (24 hours notice required) $85
    • Missed Physical appointment (24 hours notice required) $100 & up
    • Missed Counselling appointment $100 & up
    • Office Visit 1. Canadian resident without a valid health card $85
    • Office Visit 2. Out of country resident 2a. Above status on a weekend or holiday $110 &
      up
    • Prescription refills by phone or fax (Emergency short term refills at physicians
      discretion only) * $30
    • Driver Medical Examinations and Form Completion $150
    • Wart treatment by liquid nitrogen (Up to 3) ** $25
      NOTE: If procedure is sole reason for visit (Up to 3) ** $55
      Cost per wart, in excess of 3** $11
      ** OHIP will pay for liquid nitrogen wart treatment on genitals and feet only
    • Immunization & TB testing Form Simple: $45 & up
      Complex: $65 & up
    • Replacement Medical Notes $20 & up
    • Physical Examinations required by a third-party $150 & up
    • Medical Supplies (Splints, dressings, etc.) Individual Pricing
    • Copies of Medical Records First 20 pages: $30
      Per add’l page: $0.25
    • Travel Medical Advice Individual: $75 & up
    • Non-Ohip PAP test From $100 & up
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Medical Reports / Forms

(Excluding Examination unless otherwise noted. Cost of physical examination is $150)

    • Forms required for volunteers at nursing homes/hospitals $40
    • Back to work / Sick / Daycare Medical Notes $30
    • Notes for insurance coverage of physiotherapy, massage therapy, acupuncture, compression
      stockings & orthotics (at the request of patient) $35
    • Fitness Club Forms $40
    • Revenue Canada & Related Federal Tax Credits & Forms $83
    • Attending Physician’s Statements Including Disability Form (may include examination)
      $160
    • Replacement of immunization card $25
    • Photocopying/ Printing of Lab Results Per Page $1
    • CAS Children’s Aid Application For Prospective Foster Parent $65
    • Life Insurance Death Certificate $54
    • Employment Insurance / Sickness Benefits (For insurance coverage at the request of the
      patient) $35
    • Day Care Application Form $30
    • Maternity Certificate / Form $30
    • Camp Form $30
    • CPP Disability Medical Form (Charge in excess of Gov’t paid fee) $85
    • CPP Narrative Medical Form Up to $150
    • Travel Cancellation Insurance Form (with examination) $115
    • • School / College / University Medical Certificate $30
    • • All other uninsured services not listed Individual Pricing

* Prescription renewals ordinarily require an office visit to re-assess the condition requiring the prescription. If you are unable to schedule an appointment to review your
medication, we will charge for this service. Please anticipate your renewals, ask for renewals at each visit and bring your medications for your appointments.

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General Information