Website Intake Form Website Intake FormWhich Clinic: Calgary Grande Prairie High River LethbridgeName* First Name Last Name DOB* MM slash DD slash YYYY Alberta Personal Health Number*Contact Phone number*Email Address (okay to contact)* Preferred method of contact Phone Call EmailMailing Address*CitiesProvincesAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonPostal Code*Parent/Guardian/Support Person NameParent/Guardian/Support Person Phone/Email (if different from above)Government/Compensation funding:Choose Funding SourceChoose Your Funding SourceWorker's Compensation Board –AlbertaVeteran’s Affairs CanadaNon-Insured Health Benefits for First Nations and InuitRCMP (K-Div)Department of National Defense (DND)WorkSafe BCWSIB (Ontario)WSCC (Nunavut/Northwest Territories)Worker's Compensation Board –SaskatchewanWorker's Compensation Board –ManitobaWorker's Compensation Board –New BrunswickWorker's Compensation Board –Prince Edward IslandWorker's Compensation Board –NewfoundlandWorker's Compensation Board –YukonOtherClaim NumberDo you require an accessible appointment? Yes NoNote: We will call you back if you check Yes