Clinic Registration

CanCare Clinic is dedicated to providing the best Healthcare available. Our service is personal so you can be confident in knowing that your personal needs are being met. In addition to their expertise, our staff members bring warmth, caring and sensitivity. A link to our Clinic registration forms in Word and PDF is below, or you can us our Online Registration Form.

Clinic Registration - PDF Document (Adobe Reader required)
Clinic Registration - Word Document

Fill out the form below and we will respond to you by the next business day.

Personal Information  
Last Name:
First Name:
MI
Street Address in Canada:
Apartment Number:
City:
Province:
Zip Code:
Canadian Phone Number:
Florida Phone Number:
Email:
Social Security or Government ID Number:
Birth Date:
Marital Status:
Spouse's Name:
Florida Street Address
Apartment Number:
City:
State:
Zip Code:
Date of Departure:
Date of Return:
Travel Insurance Information  
Company:
Policy #:
Agent:
Province:
Phone Number:
Company Email:
Name on Policy:
Emergency Contact Information  
Last Name:
First Name:
MI
Street Address:
Apartment Number:
City:
Province:
Zip Code:
Phone Number:
Relationship:

 

Recognition of Debt

I pledge to forward to Bay Area Medical and CanCare Clinic any and all payments received from the Provincial Health Insurance, and for my private or travel Insurance for services rendered to me, unless I had pay the services in full at the time of my visit. I recognize that I'm responsible to the physician and to the clinic for the fees charged, even if the Insurance Company refuses to pay for any reason whatsoever. I know that I might be subjected to legal procedures in Canada and in Florida if the account is not entirely settled, in US currency, within the stipulated period. I assign all Insurance benefits to the Doctors and Healthcare workers of the CanCare office and of Bay Area Medical.

Electronic Signature:

Type your name and your date of birth:
         

Type Today's date:

 

 

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Bring in any CanCare Clinic or Bay Area Medical advertisement to receive a
$10 discount on our Cardiovascular Heart and Stroke Screening.
Our advertisements can be found in the St. Pete Times Neighborhood section and other local publications.

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