Accessibility Medical Appointments

Accessibility - Booking Medical Appointments

** Please read before completing the form**

Use this appointment request form if you are unable to book an appointment by telephone due to unique circumstances or accessibility challenges. While Health Services has developed an online booking system, most appointment bookings are handled by telephone at 778 782 4615.

Please note that appointment requests are not confirmed until a medical office assistant contacts you by email. This process may take 2-3 business days, and appointments are currently booked 2-3 weeks in advance.

** This request form is NOT intended for crisis or emergency purposes. If you are in an emergency, please call 911, MySSP, or go to your nearest hospital emergency department.**

The information collected is used to verify your identity and understand your needs so that we can book your appointment. Health and Counselling Services (HCS) staff will review this information and keep it confidential.

This is not a confirmed appointment. A medical office assistant will email you within 2-3 business days. You will need to complete a set of forms and confirm a suitable appointment time with the assistant. Thank you for your patience.

Collection of Personal Information

Simon Fraser University collects through its websites, telephone services and departmental office forms personal information from students, alumni, and employees.

The University collects this information under the general authority of the University Act (R.S.B.C. 1996, c. 468) and other applicable administrative policies approved by the University's Board of Governors; other provincial or federal legislation or regulation; and, binding legal contracts such as collective agreements.

All personal information provided for the University’s administrative and operational purposes and any other information placed into a student, alumnus, employee personal record will be collected, protected, used, disclosed and retained in compliance with British Columbia’s Freedom of Information and Protection of Privacy Act (R.S.B.C. 1996, c. 165).

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* 1. Please provide the most up-to-date information:

Legal Name (First/Last):

Preferred Name:

Pronouns:

Student Number:

Birthdate:

Street Address:

City:

Postal Code:

Phone Number:

SFU email address:

Emergency Contact Name and Phone Number:

Relationship of Emergency Contact:

Are you a Domestic or International Student?

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* 2. Medical Insurance Information

Personal Health Number (found on your BC Services Card):

Other Province Health Card & Number

Guard.Me Insurance Number and expiry date:

Pay Privately

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* 3. Have you ever seen a provider at SFU Health & Counselling Services (a doctor, counselor, mental health nurse, registered nurse, or transition case manager)?

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* 4. Who would you like to book an appointment with?

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* 5. What type of appointment would you like to book with us?

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* 6. Briefly describe the reason for this appointment

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* 7. Briefly describe the reason for using this form (optional)

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* 8. Please indicate all days/times you are available for an appointment within the next couple of weeks during business hours (9:30 a.m. - 4:00 p.m.). List as many availability options as possible so we can accommodate your schedule. We cannot guarantee the appointment time or the provider's availability, but we will provide you with options to meet your needs.

Monday

Tuesday

Wednesday

Thursday

Friday

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* 9. If you would like to see a specific provider or prefer to be seen by a particular gender, please indicate below. Leave blank if you have no preference.