Registration request for World Diabetes Day Event

Thank you for your interest in this event/program. Please complete and submit the form below.

Timeslot:

Thursday 12th Nov 2020, 12:00pm - 1:00pm

Location:

Virtual Mtg

Nom:

Date of Birth:

Parent/Guardian:

OHIP #:

Courrier électronique:

Confirmer le courriel:

Numéro de téléphone:

Address Line 1:

Address Line 2:

Town/City:

Province:

Postal Code:

Médecin:

Message:

1. All your information is treated confidentially.

2. If you are registering on behalf of someone else (e.g. dependent, child), please enter the date of birth and health card of that person.