DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Please be advised that all co-payments are due on the day of service. If collection should ever be required on your account, collection expenses will be incurred by the responsible party.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use:
Copyright © 1999-2020 Hush Communications Canada Inc.