The Mole Clinic

Request for Appointment - Patient Information

Complete this form for an Online Appointment to assess your skin issue. 
 
Your response will be reviewed by a licensed medical doctor and you will be called on the provided phone number(s) to discuss your concerns.  OHIP will only be billed if the concern is medical.  At the discretion of the medical doctor, he/she may elect to have you book an in-person consultation at our clinic.
 
Depending on consultation request volumes, please allow up to 5 business days to respond to your request.
 
The Mole Clinic respects your privacy.  Your answers are encrypted for your safety and security. This form is completely optional and you do not need to complete it to get service at our clinic.
 
If you do not feel comfortable providing the information, please call us at 877-336-6537 to speak to a staff member instead or to book an in-person appointment.
Please indicate the best way to contact you (we prefer your mobile number as we are able to directly text you appointment information):
Can we leave a voice message if you are not available? *
Have you contacted us or visited our clinic before? *
Days / times of Week you are Available - select as many as you wish
 TuesdayWednesdayThursdayFriday
10:00am to 11:00am
11:00am to 12:00pm
12:00pm to 1:00pm
1:00pm to 2:00pm
2:00pm to 3:00pm
3:00pm to 4:00pm
4:00pm to 5:00pm

Tell us about your concern

Type of skin concern *

Did you review this problem with your family doctor? *
Are you concerned about skin cancer? *