Registration | Milton Orthotic & Wellness Centre Database

Welcome to Milton Orthotic & Wellness Centre

Please provide us with some basic personal information. Fields marked with a * are required.

First name*

Last name*

Parent or guardian

Address line 1*

Address line 2

City

Postal code (format A1A1A1)*

Province

Cell phone (format: 000-000-0000)*

Secondary phone (format: 000-000-0000)

Email address

Date of Birth (YYYY-MM-DD):*

Doctor:

Referral Type:*

I consent to Milton Orthotic & Wellness Centre communicating with me by email.
(Note: We will never distribute your email information)

Referral source's name*:

Employer*

Policy Holder:

Insurance company*

Policy/Plan Number:*

Policy/Certificate ID:

Policy Holder's Date of Birth (YYYY-MM-DD):

Same as client's DOB

Employer

Policy Holder:

Insurance company

Policy/Plan Number:

Policy/Certificate ID #:

Policy Holder's Date of Birth (YYYY-MM-DD):

Client notes: