Sign-up as a Patient or Support Person Please choose the InspireHealth Centre you wish to attend:Centre*VancouverVictoriaKelownaVirtual Centre - Online CanadaContact & Personal InformationName* First Last Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Email Address* Phone*Mobile PhoneWhat is your current gender identity?*Do you have a cancer diagnosis (recent or past)?*YesNo - I am a support personPlease name the patient you are supporting. N.B. It is required that the patient is first signed-up as an InspireHealth member.*Cancer diagnosis (if applicable)Care card / provincial health number*Date of Birth* MM DD YYYY Emergency Contact information* Full Name Relationship Phone*How did you hear about us?Please specify who, Doctor, healthcare professional, friend, family member, colleague or other I would like to subscribe to the InspireHealth Newsletter and receive upcoming news, events and giving opportunities. I would like to receive reminders about upcoming programs and classes.
