FHO After Hours

CREDIT VALLEY HEALTH CENTER

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FHO After Hours
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Flu Vaccine Consent Form

Compassionate Care Family Health Organization
Call this number to find out which doctor is on-call: 905-766-3079

After Hours Phone Call Request
- these form submissions are only monitored on FHO After Hours dates for URGENT requests only
- requests will only be accepted for a 3 hour window, starting at 5pm on weeknights and 10am on Saturdays
- FHO after hours service is reserved for rostered family practice patients
- if it is an emergency, please call 911 or go to the nearest Hospital's Emergency Dept.

Please fill out the following form to request a FHO after-hours appointment

* Indicates required field

Name *

First

Last

Gender (as it appears on your driver's licence) *

Male Female X

Date of Birth (dd/mm/yyyy) *

Health Card *

Version Code *

Phone Number *

Email *

Family Doctor *

Reason For Request (please leave as much detail as possible) *

Is this an urgent matter? *

Yes

FHO after hours appointments are for urgent matters only. If non-urgent, please call your family doctor for further direction

Staff will triage each request based on all information given. If you feel that it is an emergency, please go to the nearest Hospital Emergency Dept.

Symptoms (Check all that apply) *

N/A Fever Cough Respiratory Pain Rash/Skin issue Mental Health Other

Please further describe your symptoms *

How long have you been having these symptoms *

N/A 1 day or less 2-3 days 3-7 days 7+ days

Have you taken any medications to manage your symptoms? *

N/A Yes No

If yes, please list the medications you have taken *

Please note: You may receive a call/email from staff to go over your request OR a call directly from your doctor. This call may be from a blocked/unknown number. Our clinic will not be receiving calls after hours, on weekends or on holidays - so please make sure you do your best to answer our calls so we can manage your care in a timely fashion.

I Understand

Submit

Credit Valley Health Center
16-2555 Erin Centre Blvd
Mississauga ON, L5M 5H1
Phone: 905-828-0270
Fax: 905-828-0277

Home
RX RENEWAL
Request Appointment
Book With Hazel
REGISTER
FHO After Hours
Speak to a Receptionist
Flu Vaccine Consent Form

Compassionate Care Family Health OrganizationCall this number to find out which doctor is on-call: 905-766-3079

Please fill out the following form to request a FHO after-hours appointment

Compassionate Care Family Health Organization
Call this number to find out which doctor is on-call: 905-766-3079