Class Registration Request

Please be aware that this form is for a registration REQUEST only and does not automatically enroll you for this class. Once your request is received, a scheduling coordinator will contact you to confirm your registration or get more details from you.

Class information

Contact information

First Name *

Last Name *

Email Contact *

Telephone/Cell *

Postal Code (for client validation)

Date of Birth (yyyy-mm-dd) *

Gender
MaleFemaleIdentifies as OtherDecline to indicate

Provider Information

Your Family Doctor * (Please type the name of your Family Doctor (or type n/a if you don't have a doctor)

Your Doctor's Clinic * (Please type the name of your clinic (or type n/a if you don't have one)

I allow PCN to contact my medical provider with my information

I allow PCN to contact me electronically

* Denotes required field.