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PROFILE UPDATE
1
E-mail
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example@example.com
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2
Full Name
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First Name
Last Name
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3
Mobile Number
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4
Current Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Afghanistan
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Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
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Guadeloupe
Guam
Guatemala
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Guinea
Guinea-Bissau
Guyana
Haiti
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Hong Kong
Hungary
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India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
Kiribati
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South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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5
Type of Practitioner (Primary)
*
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(scroll)
Registered Massage Therapist
Physiotherapist
Chiropractor
Medical Doctor
Nurse Practitioner
Acupuncturist
Naturopathic Doctor
Occupational Therapist
Kinesiologist
Physiotherapist Assistant
Osteopath
Registered Massage Therapist
Physiotherapist
Chiropractor
Medical Doctor
Nurse Practitioner
Acupuncturist
Naturopathic Doctor
Occupational Therapist
Kinesiologist
Physiotherapist Assistant
Osteopath
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6
Registration Number (Primary)
*
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7
Date of Registration
-
Date
Year
Month
Day
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8
Do you have second Practitioner License?
YES
NO
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9
Type of Practitioner (Secondary)
(scroll)
Registered Massage Therapist
Physiotherapist
Chiropractor
Medical Doctor
Nurse Practitioner
Acupuncturist
Naturopathic Doctor
Occupational Therapist
Kinesiologist
Physiotherapist Assistant
Osteopath
Registered Massage Therapist
Physiotherapist
Chiropractor
Medical Doctor
Nurse Practitioner
Acupuncturist
Naturopathic Doctor
Occupational Therapist
Kinesiologist
Physiotherapist Assistant
Osteopath
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10
Registration Number (Secondary)
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11
Date of Registration (secondary)
-
Date
Year
Month
Day
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12
Would you like to update your
banking Information
Add or update banking information
YES
SKIP (NO Changes)
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13
Let's get your banking information setup for payments! Which institute do you
Bank
with?
(scroll)
BMO (001)
Scotiabank (002)
RBC (003)
TD Canada Trust (004)
National Bank (005)
CIBC (010)
PC Financial (010)
HSBC (016)
Other
BMO (001)
Scotiabank (002)
RBC (003)
TD Canada Trust (004)
National Bank (005)
CIBC (010)
PC Financial (010)
HSBC (016)
Other
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14
What is your bank transit/branch number ?
5 digit - 12345
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15
What is your bank account number?
Usually a 7-digit number - 1234567
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16
If you have a copy of a VOID check. Please upload
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Max. file size
: 10.6MB
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17
Updated Emergency Contact Name
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18
Emergency Contact Number
Please enter a valid phone number.
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19
Do you have an HST or Business number?
YES
NO
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20
HST or Business Number
Please enter your HST# or Business
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21
Full Legal Name of Business
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22
Your SIN #
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23
Date of Birth
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Month
Day
Year
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24
Update Profile Picture (Next to Skip)
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25
Updated Car Make & Model
We can help coordinate visitors parking with clients.
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26
License Plate Number
We can help coordinate visitors parking with clients.
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27
HCAI Provider Consent
We are an HCAI facility. If you work with MVA patients you agree to give us permission to bill through HCAI and you agree with HCAI provider terms and agreements http://home.hcaiinfo.ca
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28
Receipts & Billing Consent
You give WellCalm & WellBloc permission to bill and send receipts on your behalf to your clients and patients.
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29
You confirm that you are in good standing with your regulated professional College of Ontario.
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30
You confirm that you hold
valid professional liability insurance
with coverage of at least
$2 million.
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31
Terms & Agreement - Self Employment
I have read and understand our terms & conditions and service etiquette (https://wellcalm.com/legal). I confirm I am or will be self employed and understand that WellCalm and WellBloc is not an employer. Note: MVA & Treatment Plan Clients are paid via invoice, bi-weekly or monthly.
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32
Shirt Size
Universal Size
Extra Small (XS)
Small (S)
Medium (M)
Large (L)
Extra Large (XL)
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33
Select the type of clients that you would like to work with
ON DEMAND @HOME
MEMBERS @HOME
WELLCALM@WORK
MVA & RECOVERY
CLOUDCARE (VIRTUAL)
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