Community Diabetes Education Program of Ottawa

Self-Referral Form

NAME

ADDRESS

Phone format: (###) ###-####
If you don’t have a phone number, please type ‘no phone number’ in the comment section below, include how best to reach you (e.g., email or through someone else).”

Date of Birth *

Please tell us about yourself so that we can ensure that our program will meet your needs.

A diabetes educator from our program will review your information and then someone from our program will call you.

Phone Number: (613) 233-6655

Fax Number: 613-233-6713

Email: [email protected]

We are a proud program of Centretown Community Health Centre
Office Location:
Centretown Community Health Centre
420 Cooper St.
Ottawa, Ontario
K2P 2N6

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