FirstCare Membership Form
Thank you for your interest in our FirstCare Membership program. Please provide your information below and one of our team members will follow up with you. We look forward to supporting your healthcare needs! Have questions? Contact us at 1-888-370-8690 or info@servicefirsthealth.ca
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you a Canadian citizen:
*
Yes
No
Are you over the age of 18:
*
Yes
No
Services I am interested in:
*
FirstCare Membership (Primary Care)
Other
I would like to have access to a health care provider through FirstCare Membership program.
Yes
No
I would like more information, please contact me
Our FirstCare Membership program provides access to virtual primary care health services and other membership discounts and service benefits. A FirstCare Membership fee is $149. per year. Family members are eligible for membership as at a reduced annual cost of $89. per family member.
*
I understand this is an annual membership program that is payable upon enrolment.
I understand that if interested, my family members are eligible to join the membership program and their annual fee is payable upon their enrolment.
I require further information, please contact me.
My preferred method of contact is:
Phone call
Text
Email
Other Services I may be interested in learning more about:
*
Mental Health Services
Physical Health Services
CRA Disability Tax Credit (DTC) Form Services
Pain Management Products
Medical Equipment & Devices
Other
None
Let us know who told you about us - so we can thank them!
Prefer to Pay by eTransfer - please forward to info@servicefirsthealth.ca
Yes I will send prior to my appointment
Signature
My Products
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FirstCare Membership
Individual/First Family Member
$149.00 CAD
$
149.00
CAD
Quantity
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10
FirstCare Membership
Additional Family Member(s)
$89.00 CAD
$
89.00
CAD
Quantity
1
2
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8
9
10
Credit Card
Submit
Submit
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