Receipt Submission Form

Receipt Submission Form
HealthX Canada Inc. collects personal information solely for the purpose of verifying promotional eligibility. We do not collect or store clinical health records. For more details, please refer to our Privacy Policy.
Patient Name*

First NameLast Name
Patient Email*
example@example.com
Practice (Clinic) Name*

First NameLast Name
Provider (Dentist/Doctor) Name
Date and Time of Visit*

MonthDayYear
Date
Hour MinutesAM/PM Option
Rebooked another appointment?*

YesNo
Date of your next Appointment

MonthDayYear
Date
Hour MinutesAM/PM Option
Please upload a receipt or document showing your name, clinic name, and visit date. Do not include clinical notes, treatment plans, or diagnostic images.*

Cancelof
Rate your experience with the provider
Scale of 1-10
Submitted information will be retained for 90 days solely for verification purposes and will be securely deleted thereafter. We use Jotform, a third-party service, to collect and store form submissions. Jotform complies with industry-standard security measures to protect your data. By signing this form, HealthX Canada will use information you provide to deliver you relevant information about our services, including offerings based on your preferences. By signing this form, you are agreeing to the Terms of Use and Privacy Policy.
Signature*

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