Download the New Patient Package (PDF) before your first appointment, and find other forms you need to access various medical services.

Contents

New Patient Package Before your first appointment
UHIP New Patient Package & UHIP Authorization Form
Client Record Form Print and complete this form before your first Mental Health Screen / Assessment
Periodic Health Visit Complete this form before your Periodic Health Visit appointment
General Assessment Before your annual physical/check-up
Pre-Travel Information Before your travel clinic appointment
STI Assessment For your STI assessment/counselling appointment
Web Access Form To schedule appointments and view lab results online
Verification of illness If you need a doctor to verify that you have been ill or injured, you need this form
Medical Release To authorize the release of medical information coming to the Health & Wellness Centre
Authorization of Medical Release To authorize the release of medical information from the Health & Wellness Centre
External Referral Form For referrals from outside U of T's health & Wellness Centre

New Patient Package

The package includes five forms for you to complete before arriving for your first appointment at Health & Wellness: 

  • Web Access Form
  • Emergency Contact Form
  • Privacy/Confidentiality & Permission to Share Information
  • Cancellation Policies
  • New Patient Form

What to bring to your first appointment: updated immunization records, TB testing information, and any information related to an ongoing illness.

International students

The Package includes seven forms for you to complete before arriving for your first appointment at Health & Wellness: 

  • Web Access Form
  • Emergency Contact Form 
  • Privacy/Confidentiality & Permission to Share Information
  • Cancellation Policies
  • New Patient Form
  • Claim Authorization Form
  • Consent Form for International Patients

What to bring to your first appointment: updated immunization records, TB testing information, and any information related to an ongoing illness.

Client Record Form

Print and complete this form before your first Mental Health Screen / Assessment. Bring the completed form with you and hand it to the nurse and/or the physician who you have the appointment with.

Periodic Health Visit Form

If you would like to make an appointment for a Periodic Health Visit, please complete this form.

General Assessment Form

Complete and print this form before your appointment for a Complete Physical Exam and bring it with you to your appointment.

Pre-Travel Information Form

Bring this completed form to Health & Wellness Centre, 2nd Floor, Suite 232 when you come for your Travel Medicine appointment.

STI Assessment

If you need assessment or counselling regarding an STI (Sexually Transmitted Infection), complete this form.

Web Access Form

As a registered patient, you can schedule or cancel your appointments with Health & Wellness Centre using your Web Access account. Through this portal system, you can also view medical test results that have been released by your physician on your computer. If you have never been set up with a Web Access account, please complete this form and bring it with you the next time you visit the Centre.

Verification of illness or injury

If you need a “doctor’s note” to verify that you have been ill or injured, you need the Verification of Student Illness or Injury Form. This is the official University of Toronto form for all students who are requesting special academic consideration based on illness or injury. Please provide the form to your Physician, Surgeon, Nurse Practitioner, Registered Psychologist, or Dentist for completion. 

For more information visit the Verification of Student Illness or Injury website

Medical Release Form

If you require any of your medical information to be released from another person or agency to Health & Wellness, please complete this form. (The form was updated December 14, 2015.)

Authorization of release of medical information

If you require any of your medical information to be released from Health & Wellness to another person or agency, please complete this form. (The form was updated December 14, 2015.)

This form will permit Health & Wellness to release necessary medical information to a specific recipient.

Complete the form and submit by either:

Please note the fee must be paid before the request is processed:

  • $30 for up to 20 pages and $0.25 per page thereafter
  • $5.00 charge for postage and handling (additional postage charges may apply for US and International mailing)
  • Xpresspost (with a tracking number) is available for an addition $15.00

External Referral Form

Our client coordinator assesses and triages any external referrals (from outside the University of Toronto) received within the Health & Wellness Centre.

The referral process includes the following:

  • The referral could be completed by a Family Physician or Psychiatrist. If the referral is completed by a General Practitioner, the Psychiatrist needs to be aware, and psychiatric reports should be included.
  • The completed referral should be faxed to our intake fax line: FAX (416) 978-7341.
  • The referral will be reviewed by our Client Coordinator and this may also include a brief telephone screening, or request for more information from the referring physicians.