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

Email Consent Form

First Name

Last Name

Birthday

Email

My body temperature is lower than 98.6°F/ 37.5°C

I am not experiencing the symptoms: fever, cough, sore throat

I haven’t been in close contact with a Covid-19 patient in the last 14 days

Initials

Date

Your Signature

I declare that I have read the above information and I consent to the use of email for communication with Acton Medical and Urgent Care

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.