Phone: (613) 830-5111
Fax: (613) 830-5112
Mon - Thur. 9:00 - 20:00 Fri 9:00 - 17:00 Sat 9:00 - 12:00

WAITING LIST FORM

First Name *

Last Name *

Year of Birth *

Month of Birth *

Day of Birth *

Health Card Number *

Street Address *

City *

Postal Code *

Email Address *

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IMPORTANT NOTICE:

Please note that being on the waiting list doesn't guarantee your acceptance to the practice. Therefore, please do not contact the clinic to ask about the status of your application, we will contact you directly when you have been accepted to our practice.

I AGREE TO TRANSFER MY INFORMATION IN THIS EFORM ELECTRONICALLY AND I FULLY UNDERSTAND THE RISK.

First Name