This form is for parents to complete before the visit.
We look forward to seeing you and your child.
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 © 1999-2022 Hush Communications Canada Inc.