Appointments To book an appointment, please complete the form below. Reason for Appointment When You Visit Us Please bring a full list of prescription medications with you.Have you been to JEMA before? Yes No If No, please bring a list of immunuzations and dates received. Please also provide a record of all childhood immunizations. If you were born in Newfoundland, please contact Public Health Records at 752-4894. How did you hear about our clinic? If you are visiting us because you are travelling, please complete:Date of Departure MM slash DD slash YYYY Length of Stay Countries to Visit Reason for Appointment Request*WorkVacationVolunteerEducationalMovingOtherNumber of Individuals Needing Appointment*1 Person2 People3 People4 People5-10 PeopleMore than 10 PeopleIf work related, please provide company contact information:Traveler #1 Name First Last Date of Birth MM slash DD slash YYYY Family Doctor's Name Phone Number (h)Phone Number (w)Phone Number (c)Mailing AddressEmail* Traveler #2Name First Last Date of Birth MM slash DD slash YYYY Phone Number (h)Phone Number (w)Phone Number (c)Mailing AddressEmail Traveler #3Name First Last Date of Birth MM slash DD slash YYYY Phone Number (h)Phone Number (w)Phone Number (c)Mailing AddressEmail Traveler #4Name First Last Date of Birth MM slash DD slash YYYY Phone Number (h)Phone Number (w)Phone Number (c)Mailing AddressEmail Traveler #5Name First Last Date of Birth MM slash DD slash YYYY Phone Number (h)Phone Number (w)Phone Number (c)Mailing AddressEmail Traveler #6Name First Last Date of Birth MM slash DD slash YYYY Phone Number (h)Phone Number (w)Phone Number (c)Mailing AddressEmail EmailThis field is for validation purposes and should be left unchanged.
