Doctor Name (required)
Doctor Telephone (required)
Fax / Address
Name (required)
Patient's Age
Patient's Phone
Address
Private Insurance Social Insurance No Insurance
Radiographs Taken? Yes No
Medical Alerts? / Comments?
265 Carling Ave. Suite 100 Ottawa, ON. K1S 2E1
Tel: (613) 518-2147 Email: info@drji.ca