Download the New Patient Package (PDF) before your first appointment, and find other forms you need to access various medical services.

Contents

New Patient Package Before your first appointment
UHIP New Patient Package for International Students
External Referral Form To refer a currently registered U of T student to U of T’s Health & Wellness Centre for brief episodic mental health care
Client Record Form Print and complete this form before your first Mental Health Screen / Assessment
Periodic Health Visit Complete this form before your Periodic Health Visit appointment
General Assessment Before your annual physical/check-up
Pre-Travel Information Before your travel clinic appointment
STI Assessment For your STI assessment/counselling appointment
Web Access Form To schedule appointments and view lab results online
Verification of illness If you need a doctor to verify that you have been ill or injured, you need this form
Medical Release To authorize the release of medical information coming to the Health & Wellness Centre
Authorization of Medical Release To authorize the release of medical information from the Health & Wellness Centre

New Patient Package

The package includes five forms for you to complete before arriving for your first appointment at Health & Wellness: 

  • Web Access Form
  • Emergency Contact Form
  • Privacy/Confidentiality & Permission to Share Information
  • Cancellation Policies
  • New Patient Form

What to bring to your first appointment: updated immunization records, TB testing information, and any information related to an ongoing illness.

New Patient Package for International Students

The Package includes seven forms for you to complete before arriving for your first appointment at Health & Wellness: 

  • Web Access Form
  • Emergency Contact Form 
  • Privacy/Confidentiality & Permission to Share Information
  • Cancellation Policies
  • New Patient Form
  • Claim Authorization Form
  • Consent Form for International Patients

What to bring to your first appointment: updated immunization records, TB testing information, and any information related to an ongoing illness.

External Referral Form

*This section was updated on March 14, 2017.

If you are seeking mental health care at the Health & Wellness Centre and you have been under the care of another physician (Family Physician or Psychiatrist) or a counsellor (Psychologist, Psychotherapist, Social Worker, etc.), please complete the External Referral Form with your referring clinician.

What you need to know about the external referral process

  1. The referral form can be completed by a Family Physician, Psychiatrist, Psychologist, Psychotherapist, or Social Worker. If the referral is completed by a Family Physician and the student / patient has also seen a Psychiatrist, the Psychiatrist needs to be aware, and psychiatric reports should be included.
  2. The student / patient must complete and sign the last two pages to authorize and consent the release of patient’s health information.
  3. The completed referral should be faxed to our intake fax line: FAX 416-978-7341.
  4. Our client care coordinator will assess and triage the referrals. The Client Care Coordinators may request a brief telephone screening or more information from the referring clinician.

Client Record Form

Print and complete this form before your first Mental Health Screen / Assessment. Bring the completed form with you and hand it to the nurse and/or the physician who you have the appointment with.

Periodic Health Visit Form

If you would like to make an appointment for a Periodic Health Visit, please complete this form.

General Assessment Form

Complete and print this form before your appointment for a Complete Physical Exam and bring it with you to your appointment.

Pre-Travel Information Form

Bring this completed form to Health & Wellness Centre, 2nd Floor, Suite 232 when you come for your Travel Medicine appointment.

STI Assessment

If you need assessment or counselling regarding an STI (Sexually Transmitted Infection), complete this form.

Web Access Form

As a registered patient, you can schedule or cancel your appointments with Health & Wellness Centre using your Web Access account. Through this portal system, you can also view medical test results that have been released by your physician on your computer. If you have never been set up with a Web Access account, please complete this form and bring it with you the next time you visit the Centre.

Verification of illness or injury

If you need a “doctor’s note” to verify that you have been ill or injured, you need the Verification of Student Illness or Injury Form. This is the official University of Toronto form for all students who are requesting special academic consideration based on illness or injury. Please provide the form to your Physician, Surgeon, Nurse Practitioner, Registered Psychologist, or Dentist for completion. 

For more information visit the Verification of Student Illness or Injury website

Medical Release Form

If you require any of your medical information to be released from another person or agency to Health & Wellness, please complete this form. (The form was updated December 14, 2015.)

Authorization of release of medical information

If you require any of your medical information to be released from Health & Wellness to another person or agency, please complete this form. (The form was updated December 14, 2015.)

This form will permit Health & Wellness to release necessary medical information to a specific recipient.

Complete the form and submit by either:

Please note the fee must be paid before the request is processed:

  • $30 for up to 20 pages and $0.25 per page thereafter
  • $5.00 charge for postage and handling (additional postage charges may apply for US and International mailing)
  • Xpresspost (with a tracking number) is available for an addition $15.00