CHC Application

Community Health Centre Application for Services

Instructions for filling out this form:

1. Please complete one form per family member

2. Submit the form by clicking submit button.

3. Our staff will contact you as soon as possible to arrange an appointment.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City Postal Code

Primary Phone(Required)

Other Phone

Date of Birth(Required)

Health Card Number

Please check one of the following(Required)

I currently DO NOT have a Family Doctor or Nurse Practitioner

I currently DO have a Family Doctor or Nurse Practitioner

Doctor or Nurse Practitioners Name

First Last

Doctor or Nurse Practitioners Name - (if known)

Street Address City ZIP / Postal Code

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