Add additional child
How would you ideally prefer to we contact you regarding (select one):
(Please note, this information is being requested to improve intake of your child’s Family Medical History.)
If yes, please explain and provide a copy of any legal paperwork that supports this restriction.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use:
Copyright © 1999-2021 Hush Communications Canada Inc.