Tell us about you

We use these details to share your submission with the program. Your information is kept separate from the clinical evaluation that follows.

Your name

First name

Middle name (optional)

Last name

Date of birth

Alberta Personal Health Number (PHN)

Found on your Alberta Health Care card.

Sex

FemaleMalePrefer not to say

Have you previously had surgery to release the carpal tunnel on this hand?

YesNo

Primary phone

Alternate phone (optional)

Street address

City

Province

Postal code

Preferred language

I would like an interpreter for my appointment.

If you have a family doctor, their details help the program coordinate your care.

Name

Clinic

Clinic phone

I agree to receive email from the program.

I agree to receive text messages (SMS) about my appointment.

I understand this tool is not a diagnosis, and that my information will be shared with the Carpal Tunnel Efficiency Program's intake team.