Registration – Mindbody Pain Clinics

Thank you for your interest in the OHIP funded chronic pain group sessions.

PLEASE NOTE: These group sessions are only open to Ontario residents.

In order to register for either virtual or in-person sessions, you will need to either fill in this form or,

if you prefer, call 416-322-7539 and leave a callback number if no one answers.

This information is required by the Ministry of Health and Long-Term Care.

All information submitted here is confidential.

Registration for Mindbody Pain Groups

First

Last

* Email

Confirm Email

* Date of Birth

* Address

Street Address

Address Line 2

City

State / Region / Province

ZIP / Postal Code

Country

* Telephone

* Gender

Female

Male

* OHIP Number

* OHIP Version Code (2 Letters beside the number)

* Diagnosis

* If you plan to attend Virtual Sessions, you must sign in with either your email address or your first name and initial of your last name. Enter this here for our records.

* I have read and understood the Advisory Statement about virtual care on the mindbodypainclinics.com website (https://www.ontariomd.ca) and consent to taking part in the kind of virtual care the group offers

Yes

* Please type these characters to verify you are real person

If you encounter technical difficulties, you can email us at learn@mindbodytraining.ca or call 416 322-7539.