Website Intake Form Website Intake Form Which Clinic: Calgary Grande Prairie High River Lethbridge Name* First Name Last Name DOB* MM slash DD slash YYYY Alberta Personal Health Card*Contact Phone number*Email Address (okay to contact)* Preferred method of contact Phone Call Email Mailing Address*CitiesProvincesAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonPostal Code*Parent/Guardian/Support Person NameParent/Guardian/Support Person Phone/Email (if different from above)Do you require an accessible appointment? Yes No Note: We will call you back if you check Yes Government/Compensation funding: Choose Funding SourceChoose Your Funding SourceWorker's Compensation Board –AlbertaVeteran’s Affairs CanadaNon-Insured Health Benefits for First Nations and InuitRCMP (K-Div)Department of National Defense (DND)WorkSafe BCWSIB (Ontario)WSCC (Nunavut/Northwest Territories)Worker's Compensation Board –SaskatchewanWorker's Compensation Board –ManitobaWorker's Compensation Board –New BrunswickWorker's Compensation Board –Prince Edward IslandWorker's Compensation Board –NewfoundlandWorker's Compensation Board –YukonOtherClaim Number
