Request an Appointment
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Request an Appointment



Patients Detail

Title
First Name
Last Name
Address 1
Address 2
City
Province
Country
Gender
Date of Birth

Contact Information

Email Address
Primary Phone

Would you like to be Contacted

Confirm by

Requesting an Appointment

Service / Speciality
Physician
Time Preference
Have you previously received care at FMIC
Requesting this Appointment for?

Medical Information

Describe your Current Symptoms

​​​Please note that you might not receive an email confirmation due to a technical error but we have received your request and will reach out to you soon​.

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