Request an Appointment Important Notes: A signed requisition from a licensed Ontario healthcare provider, such as Physician or Nurse practitioner is required to schedule Specialist consultations and diagnostic tests. This form is for requesting new appointments only. We do not perform Radiology tests such as X-rays, Ultrasounds, Mammography, etc.Steps: Acquire a signed requisition from your healthcare provider Fill out the form below to request an appointment Once we receive your appointment request, our booking team will contact you directly. Please allow 14 days for a response. Note: All fields with an asterisk are required.I am submitting this form as aPatientHealthcare ProviderPatient First Name*Patient Last Name*Gender*MaleFemaleOtherPatient Email Select Preferred Number*Cell Phone NumberHome Phone NumberPreferred Phone Number*Day*Please enter a value between 1 and 31.Month*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear*Please enter a value between 1979 and 2500.OHIP Number*OHIP Version Code*Patient Height*cmfeet/inchPatient Height*Patient Weight*Pounds (lb)Kilograms (kg)Patient Weight*Select All Applicable Services* Cardiology Testing Nuclear Cardiology Testing General Nuclear Medicine Testing Cardiology or Internal Medicine Consultation MRI PET-CT Available From 7 AM - 12 PM On: Monday Tuesday Wednesday Thursday Friday Saturday Available From 12 PM - 6 PM On: Monday Tuesday Wednesday Thursday Friday Saturday Available From 6 PM - 7 AM On: Monday Tuesday Wednesday Thursday Friday Saturday Other Availability or Comments