Connect to A Nurse

Please complete the following intake form to be contacted by the next available registered nurse. If you need a health assessment within the next 24 Hours please call directly at 403-479-2626.

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Client Intake Form

For general inquiries please visit our contact page here.

Section 1: Contact Information

Are you requesting an appointment on your own behalf?

Yes

Please enter your full name:

What is your relationship to the client?

Email Address

Phone Number

Client's Full Name

Section 2: Client Information

Your information is kept confidential. Read our privacy policy here.

Date of Birth

What is the reason for this visit. Please provide as much detail as possible.

Hireanurse.ca is a healthcare advertisement agency connecting individuals to healthcare providers across Alberta. We do not take liability for our listed healthcare professionals that may contact you. By agreeing to the terms & conditions below, the individual(s) written in section 1 of this form is in agreement to our Liability/Privacy Policy.

I accept terms & conditionsView Liability/Privacy Policy

Connect to A Nurse

Client Intake Form

Section 1: Contact Information

Section 2: Client Information

Your information is kept confidential. Read our privacy policy here.

Alberta, Canada 403-479-2626

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