TRT Intake - Referral2

Getting Started with your Get Gambit Visit*

Since this is a medical visit, we need to ask you some questions about your health and medical history. Questions? Read the FAQ. It likely has the answer you're looking for. By clicking "Continue", you are confirming that you:

Are completing this questionnaire for yourself and to the best of your knowledge

Will disclose any serious illnesses or surgeries you have had

Will disclose any prescription medication you currently take

Will disclose any relevant symptoms you are experiencing

By continuing, you agree to Gambit's Terms and Conditions and Privacy Policy*

I agree to the Terms and Conditions and Privacy Policy.

What is the reason for your visit?*

General Consultation

Doctor's Sick Note

Lab Requisition

Specialist Referral

Mental Health Consultation

Please describe the reasons for the Doctor's Note*

Include the addressee, relevant dates, and any additional information requested.

Please indicate which practitioner you are seeking a referral for.*

If you are requesting a specific practitioner, please enter their full name and registrant number.

Please describe your symptoms in detail.*

Include the symptoms, apparent severity, any pain or discomfort associated, and location.

How long ago did you first notice these symptoms?*

Please provide your name as it appears on your ID.*

First Last

Date of Birth*

MM slash DD slash YYYY

Email*

Password*

Enter Password Confirm Password

Please provide the province where you live*

Please provide your province of residence*

Phone number*

Do you have any allergies to any medication?*

Have you had any surgeries or hospitalizations in the past 12 months?*

Please list any prescription or over-the-counter medication you are currently taking.*

Do you have a provincial health card?*

Yes

Upload a photo of provincial health card.

Please make sure
Your card is valid
Within the frame
Your information is clearly visible

Front of Health Card*

Max. file size: 10 MB.

Back of Health Card*

Max. file size: 10 MB.

Please enter your health card number below

Please upload a selfie, ensuring your face is fully within frame, clearly visible, and not filtered in any way.*

Please make sure your face and shoulders are visible and well-lit.

Max. file size: 10 MB.

Please upload a clear picture of your ID.*

Upload a photo of government issued ID (e.g. drivers license).

Please make sure
Your ID is valid and within the frame
Your information is clearly visible

Max. file size: 10 MB.

Upload a photo of provincial health card.

Upload a photo of government issued ID (e.g. drivers license).

Thank you for submitting your information. You're one step away to completing your general visit at Get Gambit

You will be redirected to our secure, encrypted Stripe payment gateway to complete your assessment.

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