Acton Medical & Urgent Care Clinic

519-853-4449

Fax: 519-853-5242

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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!

COVID-19 Information

Acton Medical and Urgent Care is NOT a testing site for COVID-19.

Patients who are concerned that they have been exposed to COVID-19 or are having symptoms of COVID-19 are encouraged to get assessed and tested at an Assessment Centre.

The following link provides an up-to-date list of COVID-19 symptoms:

Please use the following link for COVID-19 self assessment, testing locations and checking for your COVID-19 test results:

https://covid-19.ontario.ca/?_ga=2.186312937.192118062.1585569020-2010572598.1579537951

For information about the COVID-19 Vaccine, please see the following link:

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.