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Client Application Form

Client Application Form

Client Application Form

Client Application Form

Congratulations!

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Tell us about you

First Name

Last Name

User Contact

Email

Phone Number

Address

City

Province

Postal Code

User Age

What is your date of birth?

User Age

Treatment information

Name of Clinic Preferred

Other Clinic Name

When would you like to book your appointment?

Do you currently have health coverage?

Employment information

What is your current source of income?

Other source of income

How long have you been with your current employer?

Who is your employer?

What is your employer's phone number?

Financial information

What is your hourly wage or monthly salary?

What is your pay frequency?

When is your next date of pay?

Do you currently rent or own your own property?

How much is your rent/mortgage per month?

Final step

BY CLICKING ON THE “AGREE” BUTTON IMMEDIATELY FOLLOWING THIS NOTICE, YOU: