10 Eastern Avenue

Acton, ON L7J 0A5

Acton Medical & Urgent Care Clinic

519-853-4449

Fax: 519-853-5242

actonmedicalclinic@outlook.com

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ALERTS

Welcome to our NEW Nurse Practitioner - Sandra

Acton Medical and Urgent Care will be CLOSED May 23, 2022

Telemedicine

Please complete the following Telemedicine Form

Section 1: Patient Demographic Information

Last Name

as it appears on your health card

First Name

as it appears on your health card

Date of Birth

Phone

Email Address

If you are not a current patient with Acton Medical continue answering the rest of section 1; current patients can move onto section 2.

Are you currently suffering from a medical condition, illness, or injury?

No

Yes

If you answered yes to any question, please elaborate

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Your Signature

I agree to the terms & conditions

Have you been hospitalized in the last 12 months?

No

Yes

Thanks for submitting!

If you have a medical emergency please call 911.

If you have any medical questions/concerns you can call

Telehealth Ontario at 1-866-797-0000.