Please fill out the following information, and submit to become a MCL Client.

Doctor’s Name *

Client/Office Name (Pick Up Location) *

Address *

City *

Province *

Postal Code

Billing Name

 

Billing Address

(if different to pick up location)

City

Province

Postal Code

Phone Number *

Fax Number

Email Address *

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If you are human, leave this field blank.

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