Patient's Name (First and Last)
(Required)
Patient’s Date of Birth
(Required)
Parent/Guardian Name (if applicable)
Your Relationship to the Patient (if applicable)
Contact Phone Number
(Required)
Contact Email Address
(Required)
Insurance
Select
Pacific Blue Cross
Sunlife
Canada Life
Manulife
No Insurance/Other
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Other Insurance
No insurance? Not a problem. The appointment is still complimentary.
Comments/Notes