Your email*:
Your Health Card**:
Version Code**:
Your Gender**:
select
Your Date of Birth**:
RadDatePicker
RadDatePicker
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Your First Name**:
Your Last Name**:
Apt/Suite:
Address 1*:
Address 2:
City*:
Postal Code*:  
Province:
select
Your Phone Number*:

 

DISCLAIMER

We request all individuals to read the disclaimer carefully, before proceeding with the online transactions. By entering into a clinic-patient relationship with us, the individual is acknowledging that he/she has read, understood and agreed to our terms of this disclaimer.

 

If you choose to send CLEARTONE HEARING CENTRE an email or complete any forms online, your personal information may be used in order to respond to your inquiry.

 

Collection of Personal Information

We may ask patients to provide us with details including, but not limited to:

- Patient’s Demographic Information: Name, Date of Birth, Health Card Number, Phone Number and Address

- Referring Doctor’s Information: Name, Billing Number and Phone Number

 

We may disclose your information to:

- Any parties that are mentioned/entered

- Any related parties that are involved / will be involved in providing the appropriate care to you (If Applicable)

 

Security

To ensure the privacy of the personal information you share with us via internet, we encrypt our services using a Secure Socket Layer (SSL).

Referral:

Your Physician:

First Name*:
Last Name*:
Billing #:
Address:
Phone # *:
Fax # *:

Test Type:

Comment(s):

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Avaialable Date(s):

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Time Slot(s):

Thank you for submitting your information and making an appointment with Cleartone Hearing Centre. Due to the nature of your appointment, we will contact you to schedule a time which is at your convenience.