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How It Works
Procedures
Surgical Cosmetic
Abdominoplasty
Brachioplasty
Breast Augmentation
Breast Lift
Breast Reconstruction
Breast Reduction
Buttock Lift
Chin Augmentation
Facial Implants
Forehead Lift
Gynecomastia
Mommy Makeover
Otoplasty (Ear Surgery)
Rhytidectomy (Face Lift)
Rhinoplasty (Nose Surgery)
Laser Eye Surgery
Corneal Implants
Lasik Eye Surgery
Photorefractive Keratectomy (PRK)
Hyperopia Correction
Non-Surgical Cosmetic
Injectable Treatments
Chemical Peel
Collagen Injections
CoolSculpting®
Dermabrasion
Endermologie
Laser Facial Resurfacing
Laser Hair Removal
Laser Skin Resurfacing
Non-Surgical Body Contouring
Permanent Makeup
Weight Loss
Adjustable Gastric Banding
Gastric Bypass
Gastric Sleeve
Intragastric Balloon
Weight Loss Programs
Hair Restoration
Hair Restoration
Hair Replacement
Hair Transplantation
Dentistry & Denturology
Bonding
Bleaching and Whitening
Cosmetic Contouring
Dental Surgery
Dentures and Dental Implants
Dental Laminating
Orthodontics
Veneers
Fertility
Gamete Intrafallopian Transfer (GIFT)
In Vitro Fertilization (IVF)
Intracytoplasmic Sperm Injection (ICSI)
Partial Zona Dissection (PZD)
Subzonal Insemination (SUZI)
Zygote Intrafallopian Transfer (ZIFT)
Mommy Makeover
Other
Genetic and DNA Testing
Sleep Aids and Therapy
Podiatry
Chiropractic and Rehabilitative Services
Medical Equipment and Supplies
Physician Finder
About Us
FAQs
Contact
Info for Providers
X
How It Works
Procedures
Surgical Cosmetic
Abdominoplasty
Brachioplasty
Breast Augmentation
Breast Lift
Breast Reconstruction
Breast Reduction
Buttock Lift
Chin Augmentation
Facial Implants
Forehead Lift
Gynecomastia
Mommy Makeover
Otoplasty (Ear Surgery)
Rhytidectomy (Face Lift)
Rhinoplasty (Nose Surgery)
Laser Eye Surgery
Corneal Implants
Lasik Eye Surgery
Photorefractive Keratectomy (PRK)
Hyperopia Correction
Non-Surgical Cosmetic
Injectable Treatments
Chemical Peel
Collagen Injections
CoolSculpting®
Dermabrasion
Endermologie
Laser Facial Resurfacing
Laser Hair Removal
Laser Skin Resurfacing
Non-Surgical Body Contouring
Permanent Makeup
Weight Loss
Adjustable Gastric Banding
Gastric Bypass
Gastric Sleeve
Intragastric Balloon
Weight Loss Programs
Hair Restoration
Hair Restoration
Hair Replacement
Hair Transplantation
Dentistry & Denturology
Bonding
Bleaching and Whitening
Cosmetic Contouring
Dental Surgery
Dentures and Dental Implants
Dental Laminating
Orthodontics
Veneers
Fertility
Gamete Intrafallopian Transfer (GIFT)
In Vitro Fertilization (IVF)
Intracytoplasmic Sperm Injection (ICSI)
Partial Zona Dissection (PZD)
Subzonal Insemination (SUZI)
Zygote Intrafallopian Transfer (ZIFT)
Mommy Makeover
Other
Genetic and DNA Testing
Sleep Aids and Therapy
Podiatry
Chiropractic and Rehabilitative Services
Medical Equipment and Supplies
Physician Finder
About Us
FAQs
Contact
Info for Providers
CMC Patient Applicantion Form
Patient Applicantion Form
Patient Application
Please fill in your personal information below.
Are you a Canadian Citizen or Permanent Resident?
*
Yes
No
Prefix
-----
Mr.
Mrs.
Ms.
First Name
*
Last Name
*
Your email
*
Home Phone Number
*
ex. (123) 555-5555
Work Phone Number
Mobile Phone Number
Street/House Number
*
ex. 1234
Street Name
*
ex. Grand Avenue
Apartment or Unit Number
ex. 1234
City/Town
*
Province
*
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Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
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Quebec
Saskatchewan
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Postal Code
*
Enter as A1A1A1. No spaces or dashes.
Do you Rent or Own?
Rent
Own
What is your monthly mortgage or rent payment?
Enter as 1000.99 NOT $1,000.99
Social Insurance Number (SIN)
Enter as 123-456-789
Date of Birth
*
Enter as MM/DD/YYYY e.g. 07/23/1967
Employment Information
Employment Status
*
------
Full time
Part Time
Retired
Student
Self-employed
Unemployed
Disability
Gross Annual Income
*
Enter as 1000.99 NOT $1,000.99
Name other sources of income
Ex: Disability
Total amount from other income sources
Enter as 1000.99 NOT $1,000.99
Have you ever declared bankruptcy?
Yes
No