Northern Health Connections Booking Request

Book a Trip

* First Name:

* Last Name:

* Phone Number:

* Email:

* BC Care Card Number:

* Street:

Apt (Optional):

* City:

* Province:

* Postal Code:

* Emergency Contact Name:

* Emergency Contact Phone Number:

* Employee Y/N:

I am an employee of NHC [YES]
I am not an employee of NHC [NO]

* Companion Y/N:

I require a companion [YES]
I do not require a companion [NO]

* Departure Station:

* Arrival Station:

* Trip Type:

* Travel Date:

* Purpose of Travel:

* Doctor's Name:

* Appointment Date:

Do you require assistance with any of the following:

Other Assistance Required: