Application Form

This application form can be submitted on-line, completed over the phone with our staff, or faxed by downloading the Application form on the left.
 
 
Your application will be reviewed by our clinical staff and you can expect us to contact you within 24-48hrs; to discuss a possible intake. A non- refundable payment of $250 is required to process your application. Your $250 payment is deducted from any subsequent costs at the Center.
* All Fields are Mandatory to Complete the Application Form
** For Birthdates and Phone numbers, use digits only
Name
Phone Number
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Mobile Number
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Address
Suite/Apt No.
City
State/Province
Zip Code
Country
Emergency Contact
Emergency Contact Phone Number
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Personal Health Card Number
Do you have a Canadian Health card number? Yes No
Date of Birth
Age
Sex
Do you have a Physician?
Physician's Name
Physician's Contact Phone Number
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Okay to speak to another member of household?
Okay to leave a Message?
Reasons for wanting to come to the Center now include:
Let us know how you heard about us.