Virtual Care - Provider Booking Request

Please note that this form is not for patients to book appointments

Interior Health is committed to protecting the privacy of personal information we collect through responsible information management practices. Any personal information provided to us is collected, used and disclosed in accordance with the British Columbia Freedom of Information and Protection of Privacy Act or other relevant legislation.

Please review our Privacy & Terms of Use Policy regarding collection of personal information before completing e-mailing our team.

Please note that booking an appointment requires a minimum of 48 business hours notice, and it is the requestor’s responsibility to manage their appointment details.

To book an appointment with Northern Health email telehealth@northernhealth.ca.

Personal Details

Your name:

Your email address:

Your contact number:

Your Reference #:

(if applicable)

Session Details

Doctor/Clinician attending the telehealth session:

Doctor/Clinician phone number:

Type of session:

Patient's Names:

First:

Last:

Patient Data:

PHN

DOB:

City where patient lives or can attend:

Click Here - cities with virtual care

Comments:

Date Details

Date(s) requested for session:

(YYYY-MM-DD format)

Start Time:

(Pacific Time Zone)

End Time:

(Pacific Time Zone)

(Start Time equivalent in other Time Zones)

The dates below are to be used for additional sessions (if required)

(session - #2)	Time	End time
(session - #3)	Time	End time
(session - #4)	Time	End time
(session - #5)	Time	End time

CAPTCHA

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Information for former and current IH employees on the privacy incident

Please note that this form is not for patients to book appointments

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