CMC Patient Applicantion Form

Patient Application

Are you a Canadian Citizen or Permanent Resident?*

Yes

Prefix

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*

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 Status*

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