wd1pont Fily Practice

Annual Fee RemfttanceEffective November 1, 2015

Please complete and return by November 1, 2015

U I am enclosing payment for the individual annual fee: $150.00

U We are enclosing payment for the family annual fee: $275.00

U I am on premium assistance, a student or a senior:

U individual payment enclosed $100.00U family payment enclosed $175.00

LI I/We wish to be billed for each individual service, :&

rather than pay an annual fee.

U I wish to discuss this matter privately with my doctor.

For your convenience, you may pay by either cheque or Credit Card.

Please make your cheque payable to your doctor.

U Enclosed, please find my cheque payable to my doctor; or

U Please bill my Visa Account Number

___________________________________

U Please bill my Master Card Account Number

_____________________________

U Please bill my AMEX Account Number

_________________________________

Expiry Date

__________

Name of Cardholder

__________________________

:,

Signature

Please complete the entire form and return it to us in the enclosed self-addressed enveloperegardless of your choice. It will enable us to update your records.Thank you for your co-operation.

Home: ( )___________________________________

Work: ( )__________________________________

:i

Health Card number withversion code, if applicable:

Consent to email results (via unsecured email):

Your Doctor:

Your Name:

Name(s) of Family Members:

Your Address:

City/Postal Code:

Phone Numbers:

Email Address

• (16 years of age and older)

Signature

Date