Where should the statement of account be sent if different from above:
Please present insurance cards and photo ID to medical receptionist so copies can be made.
Do we have permission to:
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.
Illnesses: Have you ever had (please check all that apply)
Are you allergic?
I authorize you to give me reasonable and proper medical care by today's standards.
Your message will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use:
Copyright © 1999-2019 Hush Communications Canada Inc.