KIDCREW | Online Booking Form | Pediatric Medical Clinic w/ Dr Dina Kulik, Toronto

New or Existing Patient(s)

Is your child (are your children) Kidcrew patient(s)?*

Existing Patient(s)
New Patient(s)

Kidcrew is now accepting new primary care patients. Specialist appointments can be scheduled after receiving a physician referral.

Please click to complete the ‘new patient’ form, and the team will get back to you within 3 business days.

Kidcrew Virtual Visits are also available to any child 0-18 years of age in Ontario. You are welcome to book your virtual visit quickly and easily. Virtual visits will allow you to speak to a pediatrician in the comfort and safety of your home. You do not need to be a current Kidcrew patient to access the virtual care team.

Thank you, Team Kidcrew

Your Contact Info (parent).

Parent's Name*

First Name Last Name

Email*

We will use this email to confirm your appointment.

Phone*

Please confirm your phone number.

Your Child's Info

How Many Children Are You Bringing for Assessment?*

One Child
Two Children
Three Children
Four Children

I'm Bringing One Child

Child's Name*

First name Last Name

Is this child a Kidcrew patient?*

Existing Patient
New Patient

Name of physician or specialist you are requesting to see?*

This visit is for?*

Please choose all that apply

Reason For Visit, or Other Details*

Please provide the reason for your visit.

Please Double-Check All Info Above (spelling, etc.)*

YES, I Double Checked

Please double check all your info, this saves time and will speed up the confirmation process.

I'm Bringing Two Children

Child (1)*

First name Last Name

Kidcrew Patient?*

Existing Patient
New Patient

Name of physician or specialist you are requesting to see?*

This visit is for?*

Please choose all that apply

(Required) Child 1 Reason For Visit, or Other Details*

Child (2)*

First name Last Name

Kidcrew Patient?*

Existing Patient
New Patient

Name of physician or specialist you are requesting to see?*

This visit is for?*

Please choose all that apply

(Required) Child 2 Reason For Visit, or Other Details*

Please Double-Check All Info Above (spelling, etc.)*

YES, I Double Checked

Please double check all your info, this saves time and will speed up the confirmation process.

I'm Bringing Three Children

Child (1)*

First name Last Name

Kidcrew Patient?*

Existing Patient
New Patient

Name of physician or specialist you are requesting to see?*

This visit is for?*

Please choose all that apply

(Required) Child 1 Reason For Visit, or Other Details*

Child (2)*

First name Last Name

Kidcrew Patient?*

Existing Patient
New Patient

Name of physician or specialist you are requesting to see?*

This visit is for?*

Please choose all that apply

(Required) Child 2 Reason For Visit, or Other Details*

Child (3)*

First Last

Kidcrew Patient?*

Existing Patient
New Patient

Name of physician or specialist you are requesting to see?*

This visit is for?*

Please choose all that apply

(Required) Child 3 Reason For Visit, or Other Details*

Please Double-Check All Info Above (spelling, etc.)*

YES, I Double Checked

Please double check all your info, this saves time and will speed up the confirmation process.

I'm Bringing Four Children

Child (1)*

First Last

Kidcrew Patient?*

Existing Patient
New Patient

Name of physician or specialist you are requesting to see?*

This visit is for?*

Please choose all that apply

(Required) Child 1 Reason For Visit, or Other Details*

Child (2)*

First Last

Kidcrew Patient?*

Existing Patient
New Patient

Name of physician or specialist you are requesting to see?*

This visit is for?*

Please choose all that apply

(Required) Child 2 Reason For Visit, or Other Details*

Child (3)*

First Last

Kidcrew Patient?*

Existing Patient
New Patient

Name of physician or specialist you are requesting to see?*

This visit is for?*

Please choose all that apply

(Required) Child 3 Reason For Visit, or Other Details*

Child (4)*

First Last

Kidcrew Patient?*

Existing Patient
New Patient

Name of physician or specialist you are requesting to see?*

This visit is for?*

Please choose all that apply

(Required) Child 4 Reason For Visit, or Other Details*

Please Double-Check All Info Above (spelling, etc.)*

YES, I Double Checked

Please double check all your info, this saves time and will speed up the confirmation process.

Your Requested Date

Preferred Date (this is a request only)*

This is a requested date only, we will confirm by email.

Time*

: HH

MM

This is your requested time, we will confirm with you by email or phone.

This is a booking request only. We will email a confirmation.*

Yes, I Understand.

This form is not a confirmed booking - we will email you a confirmation.

Confirm Your Request

IMPORTANT: Please wait for the confirmation message before closing this window.

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KIDCREW APPOINTMENT FORM

New or Existing Patient(s)

Your Contact Info (parent).

Your Child's Info

I'm Bringing One Child

I'm Bringing Two Children

I'm Bringing Three Children

I'm Bringing Four Children

Your Requested Date

Confirm Your Request

IMPORTANT: Please wait for the confirmation message before closing this window.

HOW TO KEEP COVID-19 OUT OF YOUR HOME

RESOURCE
HELP YOUR CHILD
TO WEAR A MASK

KIDCREW APPOINTMENT FORM

New or Existing Patient(s)

Your Contact Info (parent).

Your Child's Info

I'm Bringing One Child

I'm Bringing Two Children

I'm Bringing Three Children

I'm Bringing Four Children

Your Requested Date

Confirm Your Request

IMPORTANT: Please wait for the confirmation message before closing this window.

Virtual Care Visits Now Available

HOW TO KEEP COVID-19 OUT OF YOUR HOME

Success! Check Your Inbox

RESOURCEHELP YOUR CHILDTO WEAR A MASK

Success! Check Your Inbox

RESOURCE
HELP YOUR CHILD
TO WEAR A MASK