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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 SelectBeachburgCobdenEganvilleName(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 SelectNoYesThird ChoicePhone (Prefered)(Required)Type(Required)Please SelectHome PhoneWork PhoneCell PhoneNeighbourOtherAlternateAlternate PhoneTypePlease SelectHome PhoneWork PhoneCell PhoneNeighbourOtherAlternateAlternate Phone 2TypePlease SelectHome PhoneWork PhoneCell PhoneNeighbourOtherAlternateDate of Birth MM slash DD slash YYYY Do you Currenty have a Physician?(Required)Please SelectYesNoAdditional 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
