Welcome To Better Health Clinic Registration Form Please Tell Us About Yourself Page 1 of 3Personal InformationFull Name*FirstMiddleLastManitoba Health Card Number (MHSC)*6 DigitsPersonal Health Identification Number (PHIN)*9 DigitsDate of Birth*Sex*MFUKHome PhoneWork PhoneCell PhoneEmail*Home Address*NextEmergency ContactEmergency Contact Name*FirstLastPhone Number*Email AddressBackNextMedical History InformationFamily HistoryMedicationsMedical HistorySurgical HistoryAllergiesHow did you hear about Better Health Clinic?Signs/AdvertisementWord of MouthDoctor FinderOther, Please specifyPlease specify how did you hear about us?BackSendThis field should be left blank
