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  • Primary Care Program
  • Diabetes Program
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Registration Form - Primary Care Program

Register for our service - completely free for physicians

Please take a moment to complete the form below and an IDS representative will contact your practice to arrange a site inspection and an installation date.

Our Privacy Statement

The information on this form will be used strictly for registration purposes and will NOT be shared with any third-party organizations.

Contact Information * indicates a required field
Practice Name:
First Name: *
Last Name: *
Email address: *
Practice address: *
City: *
Province: *	Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
Postal code: *
Daytime telephone: *	- -
Fax number:	- -
Practice Information
How many physicians in your practice? *
Waiting room capacity:	1-10 11-20 21+
Approx. number of patients per day in entire practice: *
Agreement By submitting this form, I, the contact person listed above, understand that IDS Canada will be contacting me to discuss setting up an appointment for a site inspection and to discuss an installation date. I also understand the program is free and there are no charges for this service. The display unit and poster frame remain the property of IDS Canada.

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