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First Name*

Last Name*

Clinic Name

Physician/NP Licence #*

Note: Your subscription address must match the address on file with your respective Provincial College.

Address*

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Postal Code*

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Phone*

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My practice is primarily as a:

General Practitioner* Family Physician* Nurse Practitioner* Specialist*

Please indicate area of specialization if applicable:

How many patients (on average) do you see in one week?

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