The Mole Clinic

Request for Appointment - Patient Information

Complete this form to request an Appointment to assess your skin issue. 
 
Your response will be reviewed by a licensed medical doctor.  
 
Depending on consultation request volumes, please allow up to 3-5 business days to respond to your request. For faster service, please call us at 877-336-6537.
 
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.
Are you concerned about skin cancer? *
PLEASE NOTE:  We charge a non-refundable Consultation fee of $100 plus HST for non-medical (cosmetic) consultations.  This is payable at the time of your appointment.  This fee can be waived if you ask your doctor to refer you to our clinic.  A short referral note can be faxed to us at 519-720-0282.
IMPORTANT:  If you are concerned about skin cancer you will need to get a doctor referral faxed to us at 519-720-0282.  You can get this from your own family doctor or from a Walk-In Clinic doctor.
Please indicate the best way to contact you (we prefer your mobile number as we are able to directly text you appointment information):
I authorize The Mole Clinic to communicate with me by SMS/text messaging. NOTE: The Mole Clinic respects your privacy. Your mobile number will never be released or sold to third parties for the purpose of SMS. Opt out at anytime by replying with STOP.
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? *