Clinic Identity
Clinic Name
*
First Name
*
Last Name
*
Email
*
Phone
*
Location & Service Details
Address
Street Address
City
Province
Country
Country
Postal Code
Website (Optional)
Primary Services Offered
*
Sports Injury
Back Pain
Shoulder / Knee Rehab
Motor Vehicle Accident (MVA)
WSIB
Post-Surgery Rehab
General Physiotherapy
Other
If Other, please specify
Capacity & Handling
How many new patients can you accept per week?
*
Preferred method to receive booking requests
*
SMS
Email
Both
Typical response time during business hours
*
Billing Agreement
*
I understand CareConnect Platform only invoices for confirmed appointments.
Service Commitment
*
I agree to respond promptly to CareConnect booking requests and maintain timely communication with patients.
Terms & Consent
*
I agree to the Terms of Service and Privacy Policy and consent to be contacted by CareConnect regarding partnership and lead delivery.
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Privacy Policy
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Terms of Service