Application Forms

Here, you can download all the forms that need to be filled out/signed and submitted in order to complete your application.

These forms are all in PDF format, and require that you have Adobe Acrobat installed on your computer. After you download the forms, you should print them and fill them in by hand. After you have completed filling in the forms, please scan and send them back to apply@ccsviclinic.ca or fax them to 1-204-452-6336.

To download a form, just click on a link below. You will need Adobe Acrobat Reader to open all files below.

1. Patient Intake Form

2. Tour Authorization & Consent

3. Hospital Authorization & Consent

4. Medical Disclaimer

5. Treatment Registry Form

1. Once you download all the forms from the above links, please print them out by clicking on the “print” button: (on the top left hand corner of each form page)
2. Once printed, fill out the forms & sign
3. Scan and send them back to apply@ccsviclinic.ca or fax them to : 1-204-452-6336.

Upon receiving your application, one of our Case Managers will contact you within 48 hours.