COST OF UNINSURED SERVICES

FORMS

DR’S CERTIFICATION SICK NOTE $20
MPI DRIVERS PHYSICAL/FORM $120
MPI ALCOHOL/DRUG REPORT FORM $20
DISABILITY INSURANCE CLAIM FORM $20/page
MODIFIED WORK DUTY FORM $20/page
PARKING PERMIT $40
CRA DISABILITY TAX CREDIT FORM $80
CRA DISABILITY TAX CREDIT FOLLOW-UP $40
PRE-OP PHYSICAL EXAM/FORMS (PRIVATE SURGERY) $120
SCHOOL/EMPLOYMENT/ADOPTIONS/SPORTS PHYSICAL/FORMS $120

MANTOUX

MANTOUX (ALL VISITS, FORMS, RESULTS, INJECTIONS $220

IMMUNIZATIONS

IMMUNIZATIONS (VISIT ONLY) NOT COVERED BY MB HEALTH $40

TRAVEL ADVICE

TRAVEL ADVICE CONSULT (VISIT ONLY) $40

PATIENTS WITHOUT VALID MHSC COVERAGE

CONSULTATIONS $120
FOLLOW-UP APPOINTMENT $60
SUTURES $300
**Any lab/diagnostic testing/forms not included

CLERICAL

PHOTOCOPIES $1/page
CHART TRANSFER FEE $40
+courier/mailing charges if applicable TBA

MISSED APPOINTMENTS (24 HOURS OR LESS)

MISSED REGULAR APPOINTMENT $40
MISSED COMPLETE PHYSICAL APPOINTMENT $80
*24 Hour cancellation notice required
**Please note- The 3rd missed appointment may result in termination from practice