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Request to Become a Referrer

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Service Information
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Service Information

Service:

Transportation to Vaccination Appointment
Organization: Ottawa West Community Support

Client Information

Client Name:

First name*

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Family/Last Name*

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Email Address:

Email (Confirmation and reminder emails will be sent here)

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Phone:

Primary Phone*

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Address:

Unit/Suite #

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Street # & Street Name*

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City*

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Province/State

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Postal/Zip Code

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Language:

What is the preferred Language?

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Client

Alternate Contact

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Alternate Contact

Alternate Contact Name:*

First name*

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Family/Last Name*

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Alternate Contact Email Address:

Email (Confirmation and reminder emails will be sent here)

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Alternate Contact Info:

Primary Phone*

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Secondary Phone

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Select the date, time, and clinic location of your appointment. You must have a booked medical appointment to request transportation.
If your clinic location is not listed below, please check off Other and enter the clinic name and/or address in the specify field.
Sélectionnez la date, l’heure et l’emplacement de la clinique de votre rendez-vous. Vous devez avoir un rendez-vous pour demander un transport
Si l’emplacement de votre clinique n’est pas indiqué ci-dessous, veuillez cocher la case Autre et entrer le nom et/ou l’adresse de la clinique dans le champ approprié.

Appointment:*

Date (yyyy-mm-dd)*

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Start Time*

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End Time:

Drop-off Options:*

Canterbury Recreation Complex, 2185 Arch Street

Eva James Memorial Centre, 65 Stonehaven Drive

Horticulture Building, 1525 Princess Patricia Way

Nepean Sportsplex, 1701 Woodroffe Avenue

Ottawa City Hall, 110 Laurier Avenue West

Queensway Carleton Hospital, 3045 Baseline Rd

Ruddy Family YMCA-YWCA, 265 Centrum Blvd

St-Laurent Complex, 525 Côté Street

The Ottawa Hospital - Civic Campus, 1053 Carling Ave

Other

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Required: choose at least one option

Additional Information

Messages:

Consent

By clicking "Finish", you agree to send this personal information to Ottawa West Community Support online.

You agree to these Terms and Conditions and Privacy Policy, which govern how your personal information is kept safe.

Notifications:

Send confirmation, change & reminder messages to < name> < email>

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Send confirmation, change & reminder messages to < name> < email>

Yes

To receive notifications, please select Yes.

Submission complete

The information has been submitted to Ottawa West Community Support, but you have some steps left:

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Summary

Reference #: -

Registrant:
Organization:

Ottawa West Community Support

Service:

Transportation to Vaccination Appointment

Inquiry Phone:

1 (613) 728-6016

Tip: Referrals can be viewed by navigating to referrals in the top menu

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Appointment Service area map

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Grey area: Service delivery area

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