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

Coming Soon

Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

First Name

Email Address

Last Name

Date of Birth

Have you been hospitalized in the last 12 months?

No

Yes

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

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.