Lanark Renfrew Health & Community Services

Whitewater Bromley Community Health Center - Client Waitlist Registration

*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.
Additional Applicants/Family Members - Please provide First, Last names and DOB (Day / Month / Year).
Feel free to provide any other information feel is necessary.