New Practice Member Form

Welcome to our office.

  • No referral is necessary, we can provide a consultation to see if you could benefit from chiropractic care. We accept Cash, Cheque, Visa, Mastercard, Debit, Discover.
  • WorksafeBC, ICBC, RCMP, DVA and Canadian Forces can be billed directly.

To become a new Practice Member, call our offices (see numbers on right) or submit the form below with your preferred times.

New Practice Member Appointment Request Form

  • Please allow up to 1 business day for confirmation.
  • All questions with an * are required

Your Full Name *

Preferred nick name :

Your Email * :

Date of Birth * :

Gender * : FemaleMale

 

Mailing Address * :

City * :

Province * :

Postal Code * :

Phone Number * :

 

Referred by *

Patient Name / Other from previous question :

Preferred Doctor * : No PreferenceDr. Colin WilsonDr. Ernie von Schilling

 

Preferred Date & Time of Appointment

  • We have select times for new patient evaluations. Please submit your first preference.

Preferred date :

Preferred time : No PreferenceMorningAfternoonEvening

* Required Questions