CREDIT VALLEY HEALTH CENTER
Home
RX RENEWAL
Request Appointment
Book With Hazel
REGISTER
FHO After Hours
Speak to a Receptionist
Flu Vaccine Consent Form
Are you looking for a Family Doctor?
Please enter your information and we will contact you to book an appointment with the doctor
Registration Form (Please fill out one form for each family member)
*
Indicates required field
Name
*
First
Last
Date of Birth (dd/mm/yyyy)
*
Gender (as it appears on your driver's licence)
*
Male
Female
X
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Email
*
If you would like to request a specific family doctor, please enter their name below.
(We cannot guarantee registration with specific doctors but we will try our best to accommodate your request)
Requested Doctor's Name
*
Submit
Home
RX RENEWAL
Request Appointment
Book With Hazel
REGISTER
FHO After Hours
Speak to a Receptionist
Flu Vaccine Consent Form