Booking Form

Please provide us with 2 to 3 weeks notice for bookings.

Every effort will be made to accommodate short notice bookings.

Please phone 613-264-8256 or 1-877-445-5777 for timely assistance.

Date of Appointment (required)

Time of Appointment (24-hour clock (ex 16:30 for 4:30pm)) (required)

Length of Visit (required)

CONTACT INFORMATION

Name (required)

Address (required)

Telephone Number

Email Address (required)

Pickup Location (if different from above)

Are you registered with either theOntario Disability Support Program (ODSP) or Ontario Works (OW)?

 ODSP
 OW

If yes, please provide the name of the doctor, registered nurse or nurse practitioner you will be visiting, or the name of the program you will be attending.

Do you require an accessible vehicle (for wheelchair or other mobility devices)?
 Yes
 No

If someone will be escorting you, please indicate their name in the box below.

Please note – your booking is not firm until we have confirmed with you by phone.