Medical File Transfer Request

I, the undersigned or the authorized person (if the patient is younger than 14 years old) authorizes the establishment below to send to ExcelleMD Private Clinics a complete copy of my file. Thank you in advance for your attention to my request and please accept my best regards.

Alberta,
  • Alberta,
  • British Columbia,
  • Manitoba,
  • New Brunswick,
  • Northwest Territories,
  • Nova Scotia,
  • Nunavut,
  • Ontario,
  • Prince Edward Island,
  • Quebec,
  • Saskatchewan,
  • Yukon