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Fields marked with a "*" are mandatory.

PERSONAL INFORMATION Make sure to enter your health card number (OHIP).
Name: *
Gender: *    
Address: *
Province: *
City: *
Postal Code: * (e.g. A1B 2C3)
Residence Phone #: * (e.g. 416-333-1111)
Business Phone #: (e.g. 416-333-1111)
Cell Phone #: (e.g. 416-333-1111)
Birthdate: *
OHIP: * (10 digits with version code if applicable, e.g. 0123456789 or 0123456789KL)

EMERGENCY CONTACT The name and phone number of someone we can contact in case of emergencies or if we cannot reach you.
Name:
Phone #: (e.g. 416-333-1111)
How are you related?:

FUNDING Select all applicable sources or agencies that will be providing you with financial support. We will contact you if we require documentation of proof.

Funding Source: *
Assistive Devices ProgramADP#
DVAK#
WSIBClaim #
Social ServicesWorker
Ontario Disability Support ProgramODSP
Ontario WorksOW
OtherOther
Self
OtherPlease specify

Note: Assistive Devices Program (ADP) funding is available to ALL Ontario residents in PROSTHETICS, ORTHOTICS & HEARING. Please consult any one of us at Calmar to clarify your eligibility.
REFERRED BY If your family doctor did not refer you to Calmar, please select the referral type and fill in their name and contact details.
Referer:
If you selected "Other", please specify:
Name:
Address:
Province:
City:
Postal Code: (e.g. A1B 2C3)
Phone #: (e.g. 416-333-1111)
Fax #: (e.g. 416-333-1111)
Email:

FAMILY DOCTOR Your family doctor's contact details.
Doctor's Name:
Address:
Province:
City:
Postal Code: (e.g. A1B 2C3)
Phone #: (e.g. 416-333-1111)
Fax #: (e.g. 416-333-1111)
Email:

LOGIN Use a combination of letters and numbers for your username.
Username: *
Password: *
Confirm Password: *
Email:
Confirm Email: