Forms, Policies and Fees

Patient Forms and Policies

The following PDF forms can be printed, completed, and returned to the Health Clinic as requested.

• Intake and Consent Form - print, complete and bring your intake and consent form.
• Request for User Activity - request a record of user activity from the Saint Mary's Student Health Clinic.
• Request for Access - request access to your personal health records.
• Request for Correction - request a correction to your personal health records.
• Complaint Form - submit a formal complaint about Student Health & Wellness.
• Email Consent Form - print, complete and bring your email consent form.
• Written Privacy Statement - FAQs on access to patient information and information on the Personal Health Protection Act.

Service and Uninsured Fees

Our team offers a variety of family practice services and aims to provide you with the best care.

Some services may have fees. There may also be fees if you are not insured. Fees are subject to change and must be paid at the time of service. Payment methods include MasterCard, Visa, American Express, and Debit.

Please Note: Patients from Quebec need to pay out of pocket, then can apply to get reimbursed from Quebec using their receipt.

Medical Service Fees

• Improper cancellation/missed appointment: $50.00
• Office visit with expired or no health card: $50.00
• Physical exam: $80.00
• Sport physical: $60.00
• Injection/vaccine: $20.00
• Ear syringing: $30.00
• Liquid nitrogen: $10.00
• Plan B: $20.67

Documentation Fees

• Forms (approximated): $40.00
• Work sick note (faculty and staff): $20.00
• Work sick note (student): $10.00
• Transfer of medical records: $25.00
• Driver's Class 4 - $75.00