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Out of Province Patients
To aid in booking an out of province or international travel stay with DMC, please complete the following screening questions. Alternatively, you can call the clinic and provide this information directly. Inquiries for pricing may be addressed to the clinic.
Patient Name & Contact
Patient Name
*
First
Last
Phone Number
*
Email
*
Local Resident Name & Contact (if necessary)
Local Resident Name
First
Last
Phone Number
Email
Referring Clinic & Contact
Referring Clinic
Phone Number
Email
Country or Province of Travel
Preferred Clinic
Select your preferred clinic
Markham
Pickering
Peterborough
Additional Comments
Email
This field is for validation purposes and should be left unchanged.
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