Patient Booking – Markham Imaging Consultants

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Name

First

Last

Acknowledgement Phone (.jpg,

Phone

Preferred Appointment Times

Our staff will contact you to confirm the dates available for your chosen time. Please note that Obstetrical Ultrasounds can only be accommodated during the day times (8:00 AM to 2:30 PM)

Preferred Location

Services

Ultrasound
X-Ray
Bone Mineral Density

Please select all that apply

File Upload (.jpg, .jpeg, .pdf, .png)

Click or drag files to this area to upload. You can upload up to 2 files.

Patient Consent for Appointment Reminders

Check this box to acknowledge consent to receive electronic (via text/SMS) appointment reminders.

Acknowledgement

We are pleased to accept electronic requisitions via email and this form. There is a risk of inappropriate disclosure when emailing a requisition from a public email domain. The patient is responsible for the security of the electronic copy of the requisition when it is on their mobile device or when it is emailed from the patient’s public email domain. We will do our utmost to maintain the security of the requisition when it is received.