Insurance Update Form

Insurance Information

You may enter details for up to THREE policies.

Insurance Policy #1

Who is the policy holder? *

Me
Someone else

Note: If you will be entering the details of your own policy, it must be entered here as Policy #1

Do you have consent to provide us with insurance information on behalf of this person? *

Yes
No

We're sorry, but without confirming that you have consent to add this insurance policy, we cannot collect the policy information on this form.

Policy holder's name *

First

Last

Policy holder's relationship to the patient *

Policy holder's birthdate *//

Policy holder's address *

Address Line 1

Address Line 2

City

Province

Postal Code

How would you like to provide the policy details? *

Enter them manually
Upload a photo/document

We require (a) the insurance company, (b) the group / policy #, and (c) the ID / certificate #.

Insurance company *

Group / Policy # *

ID / Certificate # *

Upload insurance policy #1 *

Click or drag files to this area to upload. You can upload up to 2 files.

Please only upload details for ONE POLICY here. 2 files are only permitted if your document is double-sided.

Insurance Policy #2

Would you like to add a second insurance policy? *

Yes
No

Do you have consent to provide us with insurance information on behalf of this second person? *

Yes
No

We're sorry, but without confirming that you have consent to add this insurance policy, we cannot collect the policy information on this form.

Policy holder's name *

First

Last

Policy holder's birthdate *//

Policy holder's relationship to you *

Policy holder's address *

Address Line 1

Address Line 2

City

Province

Postal Code

How would you like to provide the policy details? *

Enter them manually
Upload a photo/document

We require (a) the insurance company, (b) the group / policy #, and (c) the ID / certificate #.

Insurance company *

Group / Policy # *

ID / Certificate # *

Upload insurance policy #2 *

Click or drag files to this area to upload. You can upload up to 2 files.

Please only upload details for ONE POLICY here. 2 files are only permitted if your document is double-sided.

Insurance Policy #3

Would you like to add a third insurance policy? *

Yes
No

Do you have consent to provide us with insurance information on behalf of this third person? *

Yes
No

We're sorry, but without confirming that you have consent to add this insurance policy, we cannot collect the policy information on this form.

Policy holder's name *

First

Last

Policy holder's birthdate *//

Policy holder's relationship to you *

Policy holder's address *

Address Line 1

Address Line 2

City

Province

Postal Code

How would you like to provide the policy details? *

Enter them manually
Upload a photo/document

We require (a) the insurance company, (b) the group / policy #, and (c) the ID / certificate #.

Insurance company *

Group / Policy # *

ID / Certificate # *

Upload insurance policy #3 *

Click or drag files to this area to upload. You can upload up to 2 files.

Please only upload details for ONE POLICY here. 2 files are only permitted if your document is double-sided.

Patient Information

Your Information

Insurance Information

Insurance Policy #1

Insurance Policy #2

Insurance Policy #3