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We are committed to providing the best possible services to the people we serve.

We welcome and value our patients’ questions.

905-985-2895

Make a Payment

It’s now easier than ever to pay your bill from your own computer without leaving home using VISA, Mastercard or via Paypal.

Have your bill with the invoice number available (if you have been issued one) or choose the item that you are pre-paying for from the form below to submit payment.

Patient Name(Required)

Who is the service for?

First Last

Payee Name or Company Making Payment

If different than patient name, include your information here.

First Last Company

Contact Phone #(Required)

Please provide a phone number, so we can follow-up with you if there are any issues

What are you paying for today?(Required)

Which Doctor is your request for?(Required)

Please only select one.

Would you like us to send you a receipt?(Required)

Yes, please mail it

Yes, please email it

Email Address(Required)

Address(Required)

Street Address Address Line 2 City Province Postal Code

Prescription Renewal(Required)

Prescription Renewal - $20.00

Prescription Renewal without appointment

Drivers/Firefighter Physical & Form(Required)

Driver's Physicial & Form - $200.00

Firefighters Physcial & Form - $200.00

Fee May increase due to complexity of the exam.

Travel Advice(Required)

includes injection fee / excludes cost of serum

First patient - $70.00

2 family members - $130.00 CAD

3 or more family members - $150.00

Travel Injection only (excludes cost of serum) $30.00 CAD

TB Test for Employment(Required)

Administtration - $18

Reading - $12.00

Circumcision(Required)

Circumcision (includes assessment) - $300.00

Obstetrical Delivery Deposit(Required)

For Non-OHIP Insured patients

Deposit Fee- $3500

Dental Anesthetic(Required)

Dental Anesthetic - Wisdom Teeth - $400.00

What is the Dateof your Dental Surgery?(Required)

MM slash DD slash YYYY

Do you require a Dental Claim form for your Insurance?(Required)

A claim form will be forwarded to the dental office on your behalf if required.

Yes

Have you contacted the office to request your note or form?(Required)

Yes

No, please contact the office prior to payment

Sick Note(Required)

Sick Note fee - $23.50

Forms(Required)

There are several different types of forms. If you are unsure of the correct category, please call the office.

Note - Work Absence/Sick - $23.50

Note - Insurance (massage, orthotics, etc) -$25.00

Forms - School, Camp, etc. - $33.75

Forms - Employment, Travel - $44.75

Forms - CAS parent application - $250.00

Missed Appointment Fee(Required)

*missed appointment prices include HST

Regular Appointment - $45.20

Follow-up Appointment - $50.85

Physical Appointment - $79.10

Consult Appointment - $96.05

Surgeon/Procedure Appt - No Show - $113.00

Surgery - Late Cancellation - $113.00

Transfer of records to new physician(Required)

Written Authorization from the patient must be submitted to the office prior to release of any information.

Single Record - $30.00

Other - Have you been given an invoice?

Use this section to pay an outstanding invoice or to pay a predefined amount given to you by the office or doctor that is not outlined above.

Misc Item Description(Required)

Please provide details about the service you are paying for if an invoice # is not referenced.

Invoice #

If you have been given an invoice, please include the number here. It can be found in the top right of your invoice. Format: "aa-#####"

Patient #

Please indicate your patient #

Misc Payment Amount/Invoice Amount(Required)

Please enter your invoice/payment amount to display payment options.

Total

Payment Details

MasterCard

Visa

Supported Credit Cards: MasterCard, Visa

Card Number Expiration Date Security Code Cardholder Name

*Please allow 1-2 business days for your payment to be processed.

905-985-2895

462 Paxton Street
Port Perry, ON
L9L 1L9

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