Home page
Looking for a family physician
About Us
Programs
Patients
Contact Us
reviewusongoogle
About Us

Registration request for Gambling and Behavioural addictions


Thank you for your interest in this event/program. Please complete and submit the form below.


Timeslot:
Thursday 24th Jun 2021, 6:30pm - 8:00pm
Location:
FHT Office
Capacity:
Although this event is fully booked we are taking extra registrations.



Name:
Date of Birth:
Parent/Guardian:
OHIP #:
Email:
Confirm email:
 
Phone Number:
 
Address Line 1:
Address Line 2:
Town/City:
Province:
Postal Code:
Physician:
Message:
 

1. All your information is treated confidentially.

2. If you are registering on behalf of someone else (e.g. dependent, child), please enter the date of birth and health card of that person.