Health-related financial assistance application

Applicant Information

First Name

Last Name

Date of Birth (MM/DD/YYYY)

Country of Birth

Immigration Status

SIN

Address

Phone Number

Email

Re-enter email address

Preferred Method of Contact

Phone

Email

Mail

Marital Status

Single

Married

Common Law

Divorced / Separated

Do you have any dependent adults (over 18) living with you?

Yes

No

First Nations or Inuit Status

Yes

No

Do you have access to private medical health insurance benefits

Yes

No

First Name

Last Name

What benefits are they requesting?

Vision care

Emergency dental

Dentures

Emergency prescription drugs

Details of the request