By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
We need the name of someone we can contact in the event of an emergency as well as release medical information about your condition. Please list below.
PLEASE NOTE: If you are the PARENT OF A MINOR CHILD, you should be listed here as well as anyone else we may contact.
Please present insurance card(s) and photo ID to the receptionist to be scanned.
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.