Fill out and submit our online appointment form below. A member of our staff will contact you.

You can also be assessed by one of the doctors by calling 905 773-7843 anytime between 9 am and 5 pm, Monday through to Friday.

Online Appointment Form

(*) required field

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Services Requested:			Sleep Consultation
			Sleep Consultation followed by sleep study if indicated
			Sleep study only (Ordered by physician)

First Name:		*
Last Name:		*
Email Address:
Date of Birth:		Month Jan. Feb. Mar. Apr. May. Jun. Jul. Aug. Sep. Oct. Nov. Dec.   Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 *
Home Phone:		( )   -
Work Phone:		( )   -
OHIP #:		*
Version Code (V.C.):		*
Provisional Diagnosis:

Symptoms Leading to Referral:			Snoring
			Insomnia
			Witnessed Apnea
			Restless legs
			Excessive Daytime Sleepiness
			Abnormal behavior during sleep
			Morning headaches or sore throat
			Obesity
			Other:

Medical History:
Medications:
Referred by:
Physician Number:
Signature Date:		Month Jan. Feb. Mar. Apr. May. Jun. Jul. Aug. Sep. Oct. Nov. Dec.   Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year 2008 2009 2010 2011 2012 2013 2014 2015