Personal Information
Salutation
--select--
Mr
Mrs
Miss
Ms
First Name:
Middle Name:
Last Name:
Street:
City:
Province:
Ontario
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Nova Scotia
Northwest Territories
Nunavut
PEI
Quebec
Saskatchewan
Yukon
Other
Postal Code:
Home Phone:(xxx-xxx-xxxx)
Business Phone:(xxx-xxx-xxxx)
ext:
Cellular Phone:(xxx-xxx-xxxx)
E-Mail Address:
Date of Birth
Family Physician:
Physician's Phone:(xxx-xxx-xxxx)
In Case of emergency contact:
Emergency Contact Phone:(xxx-xxx-xxxx)
Relationship:
Referred to us by:
To establish your account please provide the following information
Your Employer:
Your Occupation:
Spouse's Name:
Spouse's Employer:
Spouse's Occupation:
Telephone:(xxx-xxx-xxxx)
Drivers License:
Major Credit Card#:
Type of credit card:
Visa
AMEX
Master Card
Discovery Card
Other
Expiration Date:
I hereby understand and agree that if any amount remains upaid on my account. I authorize Dr. Terk to debit my credit card for the unapaid balance.
Primary Carrier
Insurance company:
Employee Name:
SIN/Certificate #:
Group Policy #:
Secondary Carrier
Insurance company:
Employee Name:
SIN/Certificate #:
Group Policy #:
I authorize release to my insurance company and/or plan administrator, the information contained in claims submitted electronically.
