Time Sensitive Medical Doctor Appointment Request

This is for existing patients who require a follow up for a serious condition.
After completing this form, expect to hear from our team via email within 1-2 business days.
If you have any questions, please send us a message at hello@maudmedical.com

If your condition is not listed here, you would not qualify for this triage option

I am an existing patient of MAUD

YES

Reason for Appointment

Please indicate your reason for seeking urgent medical care:

Full Name

The name indicated on your provincial healthcare card.

First Name

Last Name

Date of Birth

Your birthday is used to gain access to your intake form and is required to make your chart

YYYY

Provincial Health Care Number

Found on your health care card. Please provide the province if it is outside of Alberta. If you do not have an Alberta health care number we will additionally ask you for a credit card number upon booking.

Mobile Phone Number

Provide us with the best number we can reach you between 8:30am - 6pm

(###)

###

####

Checkbox

Equality healthcare is efficient healthcare. It is everyones responsibility to work together to respect our public healthcare system.

I understand I will call 911 if this is a medical emergency

I understand I will go to urgent care if symptoms worsen while I wait for this appointment request

I understand this is not guaranteed appointment.

MAUD Medical Clinic

909 1 Ave NE, Calgary, AB, Canada, T2E 2L3
hello@maudmedical.com (for non medical inquiries only)

Phone: 587-352-MAUD (6283)
FAX: 1-587-510-2000 physician use only

PHYSICIAN REFERRAL FORM

Land Acknowledgement
In the spirit of respect, truth and reconciliation, we acknowledge that our clinic exists on Treaty 7 territory. Treaty 7 land encompasses the territories of the Siksika, Piikani, Kainai, and Tsuut'ina First Nations, the Stoney Nakoda, including the Chiniki, Bearspaw, and Goodstoney First Nations. MAUD Medical Clinic, in the City of Calgary (traditionally named Mohkínstsis) is also home to the Métis Nation of Alberta, Region III. We recognize that Calgary is situated on the land where the Bow River meets the Elbow River. We acknowledge the responsibility we hold to the people and land with which we exist. We are MAUD Medical, we love all.