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Sign-up as a Patient

Please choose the InspireHealth Centre you wish to attend:
Centre*
Contact & Personal Information
Name*
First Last
Address*
Street Address City Province Postal Code
Email Address*
Phone*
Mobile Phone
Gender*
Do you have a cancer diagnosis (recent or past)?*
- Yes
- No - I am a support person
Please 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
How did you Hear About Us?
Doctor - please specify who, 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.