Appointment Request Form
Please fill out the following form to provide our intake worker with information about yourself and your needs.
Please Read Before Completing
After you complete this form we will contact you within 2 business days to complete your intake and schedule an appointment. We will try 3 times to reach you. If we are unable to reach you after 3 attempts your file will be closed, but you are welcome to contact us again at your convenience to book an appointment.

An appointment booking must take place by phone with the person who the appointment is for. Family members, friends, and support people cannot book the appointment for someone else. Please let us know if you need the assistance of an interpreter, we are happy to arrange one at no cost to you to assist at your appointments.
Preferred/Chosen Name
Your answer
Full Name (as it appears on your Health Card or other insurance) *
Your answer
Gender
Your answer
Pronouns (she/her, he/him, they/them, etc.)
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Health Card Number (OHIP)
Or UHIP, IFH, or other private insurance (OHIP example 1234 123 123 XX)
Your answer
Phone Number *
Your answer
Can we leave a voicemail message and say it is SHORE Centre calling? *
Email address *
Your answer
Can we send you an email at this address? *
Address *
Your answer
City *
Your answer
Postal Code *
Your answer
First Day of Last Menstrual Period
If unknown, please leave blank.
MM
/
DD
/
YYYY
Do you have an intrauterine device (Copper IUD, Mirena, Kyleena, Jaydess) in place? If so, this will need to be removed prior to your appointment. *
Have you had a previous ectopic (tubal) pregnancy? (if yes, please seek immediate medical care) *
How did you hear about SHORE Centre? *
Your answer
Message
Please let us know if you have already had a dating ultrasound or blood work done, if you prefer a female clinician or if you need an interpreter.
Your answer
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This form was created inside of SHORE Centre.