Appointment Request Form

Please use this form to submit a request for an appointment with your primary care provider.  Please fill out the form as completely and accurately as possible to help ensure we can provide you with an appointment that will best meet your medical needs.

We will do our best to respond to your inquiry in 1-2 business days (Monday-Friday).

You will receive a phone, text, or  email confirmation from our reception staff once your appointment has been booked. This confirmation will contain important information regarding the date and time of your appointment.

This form is for NON-URGENT appointments only.  If you need an urgent appointment, please call our office at 548-483-6275.  If you are experiencing a medical emergency, please call 911 or go directly to your nearest emergency department or hospital.


PLEASE NOTE: You cannot contact your doctor or receive any medical advice via email or through online form. Please DO NOT send any medical questions through this form. This form is for appointment requests ONLY.

Appointment times are generally 10 minutes in length, but if you have multiple issues and will require a longer appointment, please inform us so we may book you an appropriate time.  Missed appointments or appointments cancelled without 24 hours notice may be charged a $35.00  fee (includes HST) to the patient.

Forms Confidentiality & Legal Disclaimer:

The forms on this website submit electronic information via email. The messages sent via email form submission and any of the information and/or files transmitted are confidential and intended solely for the use of the individual or entity to whom they are addressed. Disclosing, copying, distributing, or taking any action in reliance on the contents of this confidential information is strictly prohibited. Internet form submission via email cannot be guaranteed to be secure or error-free, as information could be intercepted, corrupted, lost, destroyed, arrive late or incomplete, or contain viruses. Belmont Medical does not accept liability for any errors or omissions in the contents of the submitted information which may arise as a result of email transmission or internet information protocols. Belmont Medical accepts no liability for the content of this email form submission, or for the consequences of any actions taken on the basis of the information provided.

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Thank you! Your message was sent successfully. We will do our best to respond to all messages in 2-3 business days (Monday-Friday). If you need an urgent appointment, please call our office at 519-894-8800.  If you are experiencing a medical emergency, please call 911 or go directly to your nearest emergency department or hospital.