Client Application

The Chatham-Kent Community Health Centres (CKCHC) accepts new clients based on our target population criteria. Please answer all questions to the best of your knowledge. This form is protected and confidential once completed and submitted.

  • NameBirth Date (dd/mm/yyyy)Health Card Number (please include version code and expiry date)SexRelationship 
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  • NameDoseDirections 
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    This section is to be completed by a person from an approved rapid referral organization only. *Please fill out section completely*
  • Name:Phone Number:Ext.: 
  • **Client must have a diagnosed SMI and be without a Doctor or Nurse Practitioner to qualify. Please ensure a diagnosis has been checked above**