Patient Intake Form

Please Create A Customer Account Before Submitting Form.

patient registration

PATIENT INTAKE FORM

Please specify whether you are a patient or caregiver(Required)

First Name(Required)

Middle Name

Last Name(Required)

Date of Birth(Required)

Gender(Required)

Phone Number(Required)

Email(Required)

K Number (Veterans Only)

Address 1(Required)

Address 2 (Apt , Ste #)

City(Required)

Province(Required)

Postal Code(Required)

Is your shipping Address the same as the residing address?(Required)

Yes

Address 1

Address 2 (Apt , Ste #)

City

Province

Postal Code

Is the shipping address a private residence?

Yes

If No Specify Establisment Name.

Primary Individual Responsible

First Last Date of Birth Relationsjip

Secondary Individual Responsible

First Last Date of Birth Relationsjip

Please upload your Medical Document or registration certificate(Required)

Accepted file types: pdf, png, Max. file size: 100 MB.

Please upload your government issued I.D or Drivers License(Required)

Accepted file types: pdf, png, jpg, Max. file size: 100 MB.

PLEASE READ CAREFULLY: (Required)

Consent(Required)

I have read the above statement and consent.

Terms(Required)

I have read, understand, and agree to all of the terms above.

Date(Required)

Signature(Required)

By checking this box you are signing