Forms
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 complete all patient information (including signature, if applicable) on the form/document and forward it in PDF format to records@bywardfht.ca. 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). Please note that fees apply for completion of forms/documents. 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
| Form Name | (Download) |
|---|---|
| Travel Questionnaire | (PDF) |
| BWFHT Patient Application for Fee Exemption | (PDF) |
| Application for Reimbursement (RAMQ) | (PDF) |
| BWFHT Preventive Health Assessment | (PDF) |
| Consent to Release Personal Health Information | (PDF) |
| Concussion Assessment | (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) |
