Brochure Request Form

Physician Name:*

Name of Contact Person:*

Shipping Address:*

City:*

Province:*

Postal Code:*

Phone Number:*

Email Address:*

Select the brochure(s) you would like to order (check all that apply)**

 Psychological Services
 Neuropsychological Services
 Dementia & Alzheimer's Screening
 Concussion Management
 Stroke & Brain Injury Rehabilitation
 Neuropsychological Evaluation
 Integrated Personal Training (IPT)
 Brain Health & Fitness
 Physiotherapy & Exercise Medicines
 Cardiac Health & Rehabilitation
 Health Coaching & Therapeutic Lifestyle Change
 Inter-professional, Comprehensive Health Assessments (with Referring Physician Report)
 Registered Dietitians

Where did you hear about the Copeman Healthcare Centre:*

 Please send me a copy of my submission


  

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