Request a virtual referral appointment with Rocket Doctor "*" indicates required fields Step 1 of 3 33% Request virtual referral appointment with Rocket DoctorFirst name*Last name*Email address* Date of birth* Year Month Day Cell number*Have you been an Ottawa Fertility Centre patient before?* Yes No Do you have a partner in your family group?* Yes No / Not applicable Sex assigned at birth* Female Male Intersex Preferred pronouns* She/her He/him They/them Do you have a current / valid OHIP?*This enables us to provide you with a no-fee appointment. If you don’t have this handy you can provide it during the call with Rocket Doctor patient care coordinator. Yes No OHIP Health card number*Version Code*Expiry Date* Year Month Day How can Ottawa Fertility Centre help you?* Interested in IVF services Interested in IUI services Interested in egg freezing Other (specify below) Other HelpMessage/specify (Please be as detailed as possible)* Add Partner DetailsPartner's First Name*Partner's Last Name*Partner's Date of birth* Year Month Day Partner's cell number*Partner's Email address* Partner's Sex assigned at birth* Female Male Intersex Partner's Preferred pronouns* She/her He/him They/them Does your partner have a current / valid OHIP?* Yes No Partner's OHIP Health card number*Partner's Version Code*Partner's Expiry Date* Year Month Day Location* Yes, my primary residence is in Ontario, Alberta or British ColumbiaAddress* Street Address Address Line 2 City ProvinceAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code By requesting an appointment, you agree to Rocket Doctor’s and Terms and Conditions, Email Communications Policy, Informed Consent and Privacy Policy
