RAPID ACCESS CLINIC CONSULTATION REQUEST FORM

45 Mill Street Toronto, Ontario M5A 3R6 Tel: 416 869 DERM (3376) Fax: 416 365 SKIN (7546) RAPID ACCESS CLINIC - CONSULTATION REQUEST form This Dermatology RAPID ACCESS CLINIC (RAC) combines the best of walk-in clinics and specialty care provided by Dermatologists certified by the Royal College of Physicians of Canada. Referring Provider: OHIP Billing #: Office Phone: Fax: Family Doctor: Family Doctor s Phone: Patient Name: Health Card #: Version Code: DOB (D-M-Y): Address: Phone: Alternate: Email: Reason for Referral: Additional Info: RAC HOURS OF OPERATION : MONDAY FRIDAY 8:00 AM TO 11:00 AM Improved ACCESS with reduced wait times All dermatological conditions seen, not just urgent cases Wound care is outside of our scope of practice Patients will be seen as soon as next business day NO appointment necessary MUST be referred Wait times will vary based on daily volume All consultations by FRCPC Dermatologists Collaborative Care Hours of RAC are subject to change.

45 Mill Street Toronto, Ontario M5A 3R6 Tel: 416 869 DERM (3376) Fax: 416 365 SKIN (7546) www.avantderm.com . RAPID ACCESS CLINIC - CONSULTATION REQUEST FORM. Confirmation or booked appointment not required.

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