Lanark Renfrew Health & Community Services
Whitewater Bromley Community Health Center - Client Waitlist Registration
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Indicates a required field
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.
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Please selected your prefered location to receive Service:
Select
Beachburg
Cobden
Eganville
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First Name:
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Last Name:
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Address 1:
Address 2:
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City:
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Province:
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Postal_Code:
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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).
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Phone(Prefered):
Alternate Phone:
Alternate Phone 2:
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Type:
Select
Home Phone
Work Phone
Cell Phone
Neighbour
Other
Alternate
Type:
Select
Home Phone
Work Phone
Cell Phone
Neighbour
Other
Alternate
Type:
Select
Home Phone
Work Phone
Cell Phone
Neighbour
Other
Alternate
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Date of Birth (Day / Month / Year):
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Do you Currenty have a Physician:
Select
Yes
No
Additional Applicants/Family Members - Please provide First, Last names and DOB (Day / Month / Year).
Feel free to provide any other information feel is necessary.
Additional Applicants:
