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Edmonton
(780) 487-8355

Fort McMurray
(780) 790-1313

Grande Prairie
(780) 402-8685

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1 (877) 880-0737

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New Client Information Form

Legal Company Name: *

Billing Information

Attn: *

Billing Address: *

Billing City: *

Billing Province: *

Billing Postal Code: *

How would you like to receive your company’s invoices? *

Email
Fax

Main Contact

Name: *

Position:

Phone:

Fax:

Email:

Further instructions required by your company, please comment below:

Preferred method(s) of receiving results.

Website

Email Only

Email with attached result

Fax

Other

If result to be reported by email/fax please provide the information below.

Email
Fax

In case of a positive result during after-hours, who should be contacted or is an email sufficient?

Name:

Phone :

Other - Please specify:

If result is POSITIVE, would you like us to send it for confirmation to GAMMA – DYNACARE?

Yes

Check below for other services needed:

Audiometric Testing	Vision Test
Spirometry Testing	Mask Fitting
Panel 10

Other

Mask Type:

North Half

North Full

3M Half

3M Full

Scott 2000

Scott 3000

Other

Name: *

Position: *

* indicates a required field.

Date: *

Please sign above using your finger or soft tipped stylist.

Edmonton

(780) 487-8355

Grande Prairie

(780) 402-8685

Fort McMurray

(780) 790-1313

No appointments necessary

OPEN24/7

New Client Information Form

Billing Information

Main Contact

Preferred method(s) of receiving results.

In case of a positive result during after-hours, who should be contacted or is an email sufficient?

Check below for other services needed:

Mask Type:

OPEN
24/7