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Renfrew County – Client Waitlist Registration
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Renfrew County - Client Waitlist Registration
Please do not submit any medical information on this form, While we take necessary steps to secure your information this form is submitted by e-mail and we we cannot garanttee the security or privacy of the communication.
If you have registed for the waitlist in the past at the Health Center there is no need register again as your name is still on the list we maintain.
Please selected your prefered location to receive Service
(Required)
Please Select
Beachburg
Cobden
Eganville
Name
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
Province
Postal Code
Email Address
This form has been completed by a third party for individual(s) without an e-mail address, please do not use the above e-mail address to contact them, use the provided Telephone number(s).
(Required)
Please Select
No
Yes
Third Choice
Phone (Prefered)
(Required)
Type
(Required)
Please Select
Home Phone
Work Phone
Cell Phone
Neighbour
Other
Alternate
Alternate Phone
Type
Please Select
Home Phone
Work Phone
Cell Phone
Neighbour
Other
Alternate
Alternate Phone 2
Type
Please Select
Home Phone
Work Phone
Cell Phone
Neighbour
Other
Alternate
Date of Birth
MM slash DD slash YYYY
Do you Currenty have a Physician?
(Required)
Please Select
Yes
No
Additional Applicants:
Additional Applicants/Family Members - Please provide First, Last names and DOB (Day / Month / Year). Feel free to provide any other information feel is necessary
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