Patient Information Firstname Lastname Date of Birth Health Card Number If private pay, enter 000 Version Code (XX) Phone Email Who do you want to see? First available medical doctor My own registered family doctor Student Health Services Mental Health Assessment Weight Loss & Weight Management Dr. Gordon Lee, DC (Chiropractor) Rachel Zeng (Psychotherapy) Kathy Lam (Couple/Family Therapy) Amelia Bowler, MADS, BCBA (Behavioural Consultant) Nutritionist & Dietitian Botox & Fillers (MD) Reason for Visit New Health Issue Followup Appointment Complete Physical Quick Visit Counseling or Psychotherapy Weight Loss Clinic Chiropractor Acupuncture Custom Orthotics Looking for New Family Doctor Comments Consent & Agreement I understand and agree:I give express consent to Spring Health Corp, Get Well Clinic, Dr. Lai and Associates, to communicate with me via electronic communications for purposes including, but not limited to: general advice, specific coaching, receiving reminders, announcements, and promotions for features, products, services, or other allied-health providers relating to my healthcare. I understand that I can unsubscribe from such communications at any time in writing. I understand that any communications through paper, phone, fax, email, or video-conferencing has inherent security and privacy risks. I endeavor to engage in safe communication practices. I understand that Get Well Clinic cannot guarantee confidentiality when communicating with insecure methods (such as email). I hereby covenant and agree to release, indemnify, and save harmless Spring Health Corp, Get Well Clinic, and their Associates and staff for any costs, losses, damages, liabilities, claims, actions, proceedings and all legal and other costs of any action whatsoever, from what may occur as a result of communicating through paper or electronic methods.Confirm you are a human: Powered by ChronoForms - ChronoEngine.com Tweet