Employee Enrollment Application

Along with a clinic selection, we will require essential employee data plus particulars of dependent and spousal information.

All data on the employee enrolment form should be completed by the HR department and passed on to the employee for signature and clinic selection.

Our administration department transfers the data to the network offices where they will have an eligibility list of employees awaiting treatment. All employee treatment will be monitored and categorized monthly. Usage reports are available upon request.

To download the enrolment form, please click on the link below. You will need to have the Adobe Acrobat Reader installed on your computer. There is also a link to download the Acrobat Reader program free if you don't have it installed on your computer.

Download Enrollment Application