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Rendez-vous de Service
Home
Services
Employee and Family Assistance
Medical Second Opinion
Disability Support Services
ElderCare
YourNurse
Chronic Disease Management
TranQool - Online Therapy and Counselling
About Humanacare
News/Blog
Resources
Contact
Login
Employee/Member Portal
Provider Login
Francais
Nos Services
Différents
Accueil
À Propos HumanaCare
Rendez-vous de Service
To Request a Service appointment, please enter the following information:
Date of Request
Date of Request
MM
DD
YYYY
Name
*
Name
First Name
Last Name
Email Address
*
May we contact you by email?
*
Yes
No
Benefits coverage by:
Name of covered Employee/Member
*
Who is the appointment for?
*
Covered Employee/Member
Family
Address
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
*
Date of Birth
MM
DD
YYYY
Primary Phone Number (including area code)
*
Primary Phone Number (including area code)
(###)
###
####
May we leave a message?
*
Yes
No
Secondary Phone Number (including area code)
*
Secondary Phone Number (including area code)
(###)
###
####
May we Leave a message at your secondary number?
*
Yes
No
If your voicemail is not private and confidential we will only leave our personal name and phone number. We will not identify the company name.
What is the best time to contact you?
*
What is the presenting problem?
*
Marital Status
*
Married/Partner
Separated/Divorced
Single
Additional Information
*
Name of Company/Organization
Thank you!