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Have you previously registered as a patient or support person at InspireHealth?*

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At this time, support people are able to engage with InspireHealth through our Group Programming or Monthly Support Person Workshop

Contact Information

Full Name*

First Last

Phone*

Mobile Phone

Email*

Enter Email Confirm Email

Would you prefer an in-person, video or by phone appointment?*

Which InspireHealth centre would you like to visit?

I would like to book a one-on-one appointment with:*

Exercise Therapist

Dietitian

Supportive Care Physician

Clinical Counsellor

I prefer to be contacted via:*

Phone Call

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Have you previously met with a Dietitian at InspireHealth?

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Have you previously met with a Supportive Care Physician at InspireHealth?

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Have you previously met with a Clincal Counsellor at InspireHealth?

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Current Patient Exercise Assessment Screening

Have you previously met with an Exercise Therapist at InspireHealth?*

Have you attended an exercise class at InspireHealth in the past three months?*

Safety is our primary consideration in all programming at InspireHealth. In order for us to ensure a safe environment in movement-based group classes, all patients attending an online exercise class must have had a consultation with an InspireHealth Exercise Therapist or attended a class in the last three months. The following questions will help us understand your health and your current exercise level.

Current activity level*

Currently active (achieving greater than 30 minutes of moderate intensity activity, three days per week for at least 3 months)

Low activity (less than 60 minutes of moderate intensity activity per week)

Inactive

Please check any current chronic conditions (in addition to cancer)

cardiovascular disease

chronic obstructive pulmonary disease (COPD)

irregular heart rhythm

high blood pressure (not currently controlled by blood pressure medication)

kidney disease

high blood pressure (currently controlled by blood pressure medication)

osteoporosis or osteopenia (low bone density)

diabetes (type 1 or 2)

osteoarthritis

other

Please specify:*

What is a recent blood pressure reading (from a doctor’s office, pharmacy, etc)?*

Do you have any of the following:

low blood count (i.e.: hemoglobin, white blood cell or platelet)

unexplained fevers

vomiting or diarrhea

pain

ostomy

severe fatigue

severe nutritional concerns

lymphedema

peripheral neuropathy (numbness/tingling/burning/pain in hands and feet)

worsening or changing physical condition

Do you have any cancer in your bones?*

Yes

Please specify:*

Have you had surgery within the past six months?*

Yes

Please specify:*

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Have you been diagnosed with cancer or with a genetic predisposition to cancer?*

At this time, new support people are able to engage with InspireHealth through our Group Programming or Monthly Support Person Workshop

New Patient Contact Information

Yes, I would like to register as a patient or support person with InspireHealth to access free supportive cancer care programs and services.

Name*

First Last

Preferred name (if different from above)

Phone*

Mobile Phone

Email*

Enter Email Confirm Email

Address*

Street Address Address Line 2 City Province Postal Code

Personal Health/BC Care Card Number

What is your gender?*

Please specify cancer or genetic diagnosis:*

Date of Birth*

Month

Day

Year

Emergency contact*

Full Name Relationship

Emergency Contact Phone*

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How did you hear about us?

Please specify who: (e.g. BC Cancer, Canadian Cancer Society (CCS), CCS Lodge, Doctor/Physician, Healthcare Professional, Family Member, Friend, Online Search, or Other).

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Please specify:*

Your first step with InspireHealth is to join an Orientation Session to learn more about our programs and services. Please select below which session you would like to sign up for:

Monday 3:00 - 3:30 pm PT (Virtual)

Wednesday 4:00 - 4:30 pm PT (In-Person in Vancouver Centre)

Thursday 5:00 - 5:30 pm PT (Virtual)

Friday 11:00 - 11:30 am PT (Virtual)

Is there anything else you would like us to know?

Online Classes & Program Reminder

I would like to receive reminders about upcoming programs and classes.

InspireHealth Newsletter Signup

I would like to subscribe to the InspireHealth Newsletter and receive upcoming programs, news, events and giving opportunities.

InspireHealth Patient and Support Person Liability Waiver*

Assumption of Risk, Release of Liability, Waiver of Claims, and Indemnity Agreement

ASSUMPTION OF RISKS
I have voluntarily chosen to participate in classes, programs, services, and/or consultations with InspireHealth Society (“InspireHealth”) medical doctors, clinical counsellors, dietitians, exercise therapists and/or other InspireHealth team members or practitioners (the “Services”). The Services may be provided remotely and/or may be provided at an InspireHealth location in Vancouver, Victoria, Kelowna or elsewhere (the “Facilities”).

1. I am aware and understand that there are risks when I participate in the Services and/or use InspireHealth Facilities. Some risks can be anticipated and some cannot.
2. The risks of participating in the Services and of using InspireHealth Facilities include, but are not limited to risks of physical injury, examples of which include: shortness of breath, dizziness, exacerbation of symptoms of my cancer or cancer treatment, increased risk of slips, trips or falls, pain of unknown origin, strains, sprains, overexertion, dehydration, fatigue, aggravation of pre-existing conditions, headaches, tingling or other unusual physical sensations, weakness, nausea, serious injury, permanent or temporary disability, death; risk of adverse psychological effects or of psychological injury, examples of which include: anxiety, depression, irritability, nervousness, trouble sleeping, thoughts of self-harm; property damage; and social or economic losses.
3. Even if InspireHealth has assessed me and provided clearance for me to participate in the Services, this does not eliminate the risks.
4. I am aware of the contagious nature of bacterial and viral diseases including the 2019 novel coronavirus disease (COVID-19) (the "Disease") and that despite any efforts by InspireHealth to reduce the risk of exposure, I may be exposed to or contract the Disease by participating in the Services, by attending InspireHealth Facilities and/or by interacting with InspireHealth staff, contractors and/or members, and that the Disease may result in serious illness, physical injury, disability, death, expenses or other losses.
5. I understand, acknowledge and accept that negligent acts, omissions, advice, or a negligent failure to warn, protect or advise me on the part of InspireHealth and/or its officers, directors, employees, contractors, consultants, volunteers, agents, instructors, therapists, insurers, sponsors, donors, representatives, members, successors, assigns may cause or increase the risk that I will suffer physical injury, psychological injury, property damage, and social or economic loss.

I UNDERSTAND, ACKNOWLEDGE AND AGREE THAT I AM VOLUNTARILY PARTICIPATING IN THE SERVICES and/or ATTENDING THE FACILITIES, KNOWING THAT THERE ARE RISKS TO DOING SO. I AGREE TO ACCEPT AND ASSUME ALL RISKS OF PHYSICAL INJURY, PSYCHOLOGICAL INJURY, PROPERTY DAMAGE, SOCIAL AND ECONOMIC LOSS, DISABILITY, DEATH, AND ANY OTHER LOSS OF ANY KIND WHATSOEVER ARISING FROM OR IN ANY WAY CONNECTED WITH THE SERVICES, MY PARTICIPATION IN THE SERVICES AND/OR MY ATTENDANCE AND USE OF THE FACILITIES, INCLUDING THOSE CAUSED OR CONTRIBUTED TO BY THE NEGLIGENCE OF INSPIREHEALTH OR OTHERS FOR WHOM OR FOR WHICH INSPIREHEALTH IS RESPONSIBLE AT LAW.

RELEASE OF LIABILITY and WAIVER OF CLAIMS
As a precondition to participating in the Services, and as consideration for the value that I will receive by participating in the Services, I agree to all the terms and conditions in this Assumption of Risk, Release of Liability, Waiver of Claims, and Indemnity Agreement (“Agreement”).

I EXPRESSLY WAIVE ANY AND ALL CLAIMS which I have or which I may, in future, have against InspireHealth and/or its officers, directors, employees, contractors, consultants, volunteers, agents, instructors, therapists, insurers, sponsors, donors, representatives, members, successors, assigns and/or anyone who or which might claim contribution or indemnity from any one of them (collectively, the “Releasees”) DUE TO ANY CAUSE WHATSOEVER AND HOWSOEVER ARISING, including on account of any PHYSICAL INJURY, PSYCHOLOGICAL INJURY, PROPERTY DAMAGE, SOCIAL AND ECONOMIC LOSS, DISABILITY and/or, DEATH, examples of which are referred to above in the “Assumption of Risks” section of this Agreement, and including those arising from, or in any way connected to the Services, my participation in the Services, and/or my attendance at and/or use of InspireHealth Facilities.
For greater certainty, I expressly waive my right to seek compensation from any of the RELEASEES FOR ANY REASON WHATSOVER, including but not limited physical injury, psychological injury, property damage, social or economic loss, death and/or disability caused by negligent acts, omissions, advice, or a negligent failure to warn, protect or advise me by any of the RELEASEES, including any breach of any duty of care owed to me pursuant to the Occupiers Liability Act, R.S.B.C. 1996, c. 303, as amended.
I covenant not to make or bring any such claims against InspireHealth or any of the Releasees, and forever release and discharge InspireHealth and the other Releasees from liability under such claims.

INDEMNITY
I AGREE TO HOLD HARMLESS AND INDEMNIFY InspireHealth and the other RELEASEES from and against any injury, loss, damage, expense. liabilities, deficiencies, claims, actions, judgments, settlements, interest, awards, penalties and fines OF ANY KIND WHATSOEVER and arising from or in any way connected with my membership with InspireHealth, my participation in the Services, and/or my attendance at or use of the Facilities, INCLUDING ALL RISKS AND CAUSES REFERENCED IN THE ASSUMPTION OF RISK AND RELEASE OF LIABILITY AND WAIVER OF CLAIMS sections of this Agreement, above.

ADDITIONAL TERMS
I further acknowledge and agree that:
1. Entire Agreement: This Agreement is the entire agreement between me and InspireHealth governing my participation in the Services and use of the Facilities.
2. Severability: If any term or provision of this Agreement is invalid or unenforceable for any reason, it shall be severed and not affect the validity and enforceability of the remaining terms or provisions.
3. Binding Agreement: This Agreement is binding on and shall benefit me, InspireHealth, the other Releasees and our respective heirs, executors, administrators, successors and assigns.
4. Governing Law: All matters arising out of or relating to this Agreement shall be governed by and construed in accordance with the laws of the Province of British Columbia and the federal laws of Canada applicable within that Province. Any claim or cause of action arising under this Agreement may be brought only in the courts of the Province of British Columbia, and I hereby consent to the exclusive jurisdiction of such courts.

I acknowledge and agree that by signing this Agreement, I HAVE READ AND UNDERSTOOD ALL OF THE TERMS OF THIS AGREEMENT AND THAT I AM VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS (on my behalf and on behalf of my heirs, executors, administrators, and next-of-kin), INCLUDING THE RIGHT TO SUE INSPIREHEALTH AND THE OTHER RELEASEES FOR ANY REASON WHATSOEVER.

I am 19 years of age or older and not under a legal disability.

I agree to the Terms of Service

Thank you for signing up as a new patient.*

To book an appointment, please check this box.

Would you prefer an in-person or video or phone call appointment?*

Which InspireHealth centre would you like to visit?

I would like to book a one-on-one appointment with:*

Exercise Therapist

Dietitian

Supportive Care Physician

Clinical Counsellor

I prefer to be contacted via:*

Phone Call

This field is hidden when viewing the form

New Patient Exercise Therapy Assessment

Current activity level*

Currently active (achieving greater than 30 minutes of moderate intensity activity, three days per week for at least 3 months)

Low activity (less than 60 minutes of moderate intensity activity per week)

Inactive

Please check any current chronic conditions (in addition to cancer)

cardiovascular disease

chronic obstructive pulmonary disease (COPD)

irregular heart rhythm

high blood pressure (not currently controlled by blood pressure medication)

kidney disease

high blood pressure (currently controlled by blood pressure medication)

osteoporosis or osteopenia

diabetes (type 1 or 2)

osteoarthritis

other

Please specify:*

What is a recent blood pressure reading (from a doctor’s office, pharmacy, etc)?*

Do you have any of the following:

low blood count (i.e.: hemoglobin, white blood cell or platelet)

unexplained fevers

vomiting or diarrhea

pain

ostomy

severe fatigue

severe nutritional concerns

lymphedema

peripheral neuropathy (numbness/tingling/burning/pain in hands and feet)

worsening or changing physical condition

Do you have any cancer in your bones?*

Yes

Please specify:*

Have you had surgery within the last six months?*

Yes

Please specify:*

By checking this box, you understand that we will review your submission will be in touch with you shortly. Please make sure to add noreply@inspirehealth.ca and info@inspirehealth.ca to your safe sender's list and check your junk/spam folder.