Welcome!  We are so excited to begin our partnership in health with you!  To ensure we have the information needed to best serve you, please complete the form below.  This information will help your WIN health care provider complete forms relating to your WSIB status.  Your information will be kept strictly confidential.  If you have any questions or concerns, please feel free to contact us.

Name *
Name
Address
Address
Telephone: Home *
Telephone: Home
Telephone: Other
Telephone: Other
May we send you information via email (e.g. Appointment reminders*, clinic related information) *
*Please note that appointment reminders are a courtesy of the clinic. We are not responsible for missed reminders due to disruptions in technical services.* *
Date Of Birth *
Date Of Birth
Gender *
Emergency Contact
Emergency Contact
Phone Number of Emergency Contact
Phone Number of Emergency Contact
Policy Holder's Name
Policy Holder's Name
How did you hear about us? *
Marital Status
Cohabitants
Past Health History (Please check all that apply) *
For Adult Females: Currently Pregnant?
Date Of Injury *
Date Of Injury
Employer Address *
Employer Address
Phone Number of Contact Person *
Phone Number of Contact Person