For third-party requested forms or reports, an appropriate assessment fee may be charged in addition to the fee charged for completion of the form/report, when the assessment is not medically necessary.
If you wish to send a form/document to a clinic provider, please forward to email@example.com . The content of the email should include the first name and last initial, as well as date of birth of the individual whom the form/document pertains to. Please include the name of intended recipient (provider). To send a photo (picture) related to a medical issue at the request of your doctor, please click here.
Note that email communication is not a secure means of communication and that the above email addresses should not be used to communicate with your provider regarding a health issue. Patients are to call the clinic and speak to one of our staff members who can relay your message to your provider.
Forms for patient use
|BWFHT Patient Application for Fee Exemption||(PDF)|
|Application for Reimbursement (RAMQ)||(PDF)|
|BWFHT Preventive Health Assessment||(PDF)|
|Consent to Release Personal Health Information||(PDF)|
|Nipissing District Developmental Screen||(PDF)|
|Primary Health Care New Patient Declaration||(PDF)|
|International prostate symptom score||(PDF)|
|Privacy – Patient Lockbox Request||(PDF)|
|Consent to Authorize Disclosure||(PDF)|