This form is for parents to complete before the check-up visit.
We look forward to seeing you and your child for your Well Check-up.
Please complete this form and click submit. We will receive it in a safe and confidential way.
Instructions: Please mark under the heading that best fits your child.
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.