Electronic Update Request - Service At Location Profile - InformAlberta

Electronic Update Request - Service At Location Profile

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Service Name

Location Name

Confidential

Yes

No

Descriptive Line/Building Name

Suite

Building Number

Street Name

Street Type

Quadrant

City

Province

Postal Code


Telephone: 780-498-3200
Toll Free: 1-888-498-9902
Fax: 780-498-3907
E-Mail: millardmail@millardhealth.com
Website: http://www.wcb.ab.ca

Is 24 Hour?

Yes

No

	12:00 AM 12:15 AM 12:30 AM 12:45 AM 1:00 AM 1:15 AM 1:30 AM 1:45 AM 2:00 AM 2:15 AM 2:30 AM 2:45 AM 3:00 AM 3:15 AM 3:30 AM 3:45 AM 4:00 AM 4:15 AM 4:30 AM 4:45 AM 5:00 AM 5:15 AM 5:30 AM 5:45 AM 6:00 AM 6:15 AM 6:30 AM 6:45 AM 7:00 AM 7:15 AM 7:30 AM 7:45 AM 8:00 AM 8:15 AM 8:30 AM 8:45 AM 9:00 AM 9:15 AM 9:30 AM 9:45 AM 10:00 AM 10:15 AM 10:30 AM 10:45 AM 11:00 AM 11:15 AM 11:30 AM 11:45 AM 12:00 PM 12:15 PM 12:30 PM 12:45 PM 1:00 PM 1:15 PM 1:30 PM 1:45 PM 2:00 PM 2:15 PM 2:30 PM 2:45 PM 3:00 PM 3:15 PM 3:30 PM 3:45 PM 4:00 PM 4:15 PM 4:30 PM 4:45 PM 5:00 PM 5:15 PM 5:30 PM 5:45 PM 6:00 PM 6:15 PM 6:30 PM 6:45 PM 7:00 PM 7:15 PM 7:30 PM 7:45 PM 8:00 PM 8:15 PM 8:30 PM 8:45 PM 9:00 PM 9:15 PM 9:30 PM 9:45 PM 10:00 PM 10:15 PM 10:30 PM 10:45 PM 11:00 PM 11:15 PM 11:30 PM 11:45 PM	12:00 PM 12:15 PM 12:30 PM 12:45 PM 1:00 PM 1:15 PM 1:30 PM 1:45 PM 2:00 PM 2:15 PM 2:30 PM 2:45 PM 3:00 PM 3:15 PM 3:30 PM 3:45 PM 4:00 PM 4:15 PM 4:30 PM 4:45 PM 5:00 PM 5:15 PM 5:30 PM 5:45 PM 6:00 PM 6:15 PM 6:30 PM 6:45 PM 7:00 PM 7:15 PM 7:30 PM 7:45 PM 8:00 PM 8:15 PM 8:30 PM 8:45 PM 9:00 PM 9:15 PM 9:30 PM 9:45 PM 10:00 PM 10:15 PM 10:30 PM 10:45 PM 11:00 PM 11:15 PM 11:30 PM 11:45 PM 12:00 AM 12:15 AM 12:30 AM 12:45 AM 1:00 AM 1:15 AM 1:30 AM 1:45 AM 2:00 AM 2:15 AM 2:30 AM 2:45 AM 3:00 AM 3:15 AM 3:30 AM 3:45 AM 4:00 AM 4:15 AM 4:30 AM 4:45 AM 5:00 AM 5:15 AM 5:30 AM 5:45 AM 6:00 AM 6:15 AM 6:30 AM 6:45 AM 7:00 AM 7:15 AM 7:30 AM 7:45 AM 8:00 AM 8:15 AM 8:30 AM 8:45 AM 9:00 AM 9:15 AM 9:30 AM 9:45 AM 10:00 AM 10:15 AM 10:30 AM 10:45 AM 11:00 AM 11:15 AM 11:30 AM 11:45 AM

Hours of Operation Note

Waiting Period Same As Service:

Yes

No

Waiting Period

Waiting Time

Waiting Unit

Waiting Period Note

Same As Service:

Yes

No

Languages

Languages Note

Wheelchair Accessible

Wheelchair Accessible Note

Other Disabled Access

Other Disabled Access Note

Transportation Description

Contact Name *

Please enter contact name.

Title

Telephone *

Please provide a phone number or email.

Email *

Please provide a valid email.

Comments

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