Valence Main Appointment Request

Please correct the errors described below.

UPLOAD YOUR REQUISITION FORM: Please upload your DOCTOR'S COMPLETED requisition form. Scan or take a clear photo with your mobile phone. Upload your requisition by clicking the link below.

Add file

Please upload a file

FIRST NAME

LAST NAME

PHONE

ADDRESS

CITY

POSTAL CODE

OHIP # (OHIP PATIENTS ONLY)

VERSION CODE (FROM HEALTH CARD)

NON OHIP

APPOINTMENT SELECTION

SELECT YOUR LOCATION

Checkbox list Select all that apply.

Ultrasound

X-Ray

Floroscopy

Mammography

Bone Density Imaging

DATE PREFERRED

TIME PREFERRED

MORNING

AFTERNOON

Covid-19 Screening: In the past 14 days have you had close contact with anyone who has been diagnosed with COVID-19 or suspected to have COVID-19?

Yes No

Your information will be encrypted.

Electronic signature

Your browser does not support capabilities required for electronic signatures.

Loading templates...

Use existing signature
Type the signature
Draw
Upload an image

Click a signature you want to use:

Clear

Drop image file here or click to select file Click here to select image file from your computer

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Use this signature or Cancel

Hushmail

Hide