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Prospective Patient

To protect your privacy, we are only asking for minimal personal information. Our staff member will collect more personal details over the phone. Depending on volume of patients, it may take our staff member 4-6 weeks to contact you.

* Indicates required field

First Name *

To protect your privacy online, we are only asking you to enter your first name.

Best Contact Number *

Age *

Gender *

Email *

Health Information - please select those that applies to you, this information helps us asses your needs better *

Arthritis Anxiety Asthma/COPD Cancer Chronic Pain Diabetes Depression Dementia Heart Disease Hypertension Kidney Disease Liver Disease Other(s)

If you selected "Other(s)" above, please elaborate. *

Do you have any outstanding ICBC or WCB claims? *

Do you currently have a GP? *

If you answered yes to above, please provide GP name and brief reason of switching *

Are you vaccinated against COVID-19? *

Comment *

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The Clinic @ Clayton Heights

P: 778.574.7202
info@clinicatclayton.com
103 - 7170 188th St, Surrey, BC V4N 6R4

Home
Book an Appointment
Schedule
BECOME A PATIENT