Completion of Form Physicals for:

• Schools/Camps, $36.00

• Admission to Day-Care, Preschool, University or any other educational institution, $36.00

• Pre-employment Certification of Fitness/Fitness Clubs, $54.00

• Hospital/Nursing Home Employees, $48.00

Completion of Licensing Forms/Certificates:

• Drivers Medical Examination, $168.00

Completion of Work and School Related Forms/Notes:

• Back to Work Notes/Sick Notes, $36.00

• University Specific Sick Note, $48.00

• Immunization Record Update and Completion of Forms for Work/School, $60.00

Insurance Certificates:

Note: An $100.00 assessment fee can be charged in addition to the insurance form fee if an assessment is necessary to obtain relevant information needed to complete the form

• OCF-18 Treatment Plan, $180.00

• OCF-3 Disability Certificate, $180.00

• OCF-19 Determination of Catastrophic Impairment, $144.00

• OCF-23 Treatment Confirmation, $174.00

• Travel Cancellation Insurance Form, $60.00

• Life Insurance Death Certificate, $60.00

• Medical Certificate for Employment Insurance Compassionate Care Benefits, $72.00

• Attending Physician’s Statement, $192.00

• System – Specific or Disease Specific Questionnaire, $120.00

• Insurance Medical Examination, $300.00

• System-Specific Examination, $144.00

• Full Narrative/Clarification Report, $480.00/hr.

Government Forms:

• CPP Disability Medical Report Form (up to), $102.00

• CPP The Narrative Medical Report (up to), $180.00

• Children’s Aid Society Application for Prospective Foster Parent, $72.00

• Medical Certificate Employment Insurance Sickness Benefits, $48.00

TB Mantoux Testing

• TB Test requested by Ministry of Health Program (e.g. Public Health) - FREE

• TB Test requested for admission or continuation in a day care, pre-school, school, college, university or other educational institution

• Charge for Form/Report Completion - FREE

• TB Test for work, $60.00 for injection, $20.00 for read

Unremunerated Report Forms:

Physician is NOT permitted to charge a patient for completion

• Application for Accessible Parking Permit/Transit Forms for Disabled

• PR Card Forms/Request for Birth Certificate Form/Canadian Passport Application

• Children’s Aid Society Form (on behalf of a child)/Ministry of Health and Long-Term Care (e.g. Limited Use,

• Assistive Devices etc.)

Chart Copies:

• Copies from the Patient’s Chart (up to 20 pages), $1.20/page

• Copy of the Full Chart (up to 20 pages), $36.00, if over 20 pages, $0.30 per page for each page

Other:

• Wart removal by liquid nitrogen, $30.00 (up to 3), $60.00 (up to 6)

• Letter/referral/rx for massage therapy, orthotics, back support, stockings etc., $30.00

• Non-Resident or Expired Health Card Visit Fee, $100.00, follow-up appointment, $50.00

• Pre-op Assessment (by General Practitioner), $180.00