Meals on Wheels Register* marks required fields. The password should be a minimum of eight characters long and must contain a minimum of one upper and lower case letter, one number and one symbol like ~!@#$%^&*?. Source of Information Information Provided By: Client(self) Other (Please specify below) Client Information * Select your gender… Male Female Rather not specify Client Language Preferences * Select preferred language… English French Albanian Arabic ASL Cantonese Chinese Croatian Dutch German Greek Gujurati Hindi Hungarian Italian Korean LSQ Macedonian Mandarin Panjabi Persian Polish Portuguese Romanian Russian Serbian Slovak Spanish Tagalog Tamil Urdu Vietnamese Other * Select language of correspondence… English French * Select indigenous identity… First Nations Non-Status Inuit Urban Métis N/A How did you hear about us? * How did you hear about us? GEM Nurse Family/Friend CCAC Doctor/Nurse Practitioner Website/Online Brochure/Flyer Hospital Hospital Discharge Planner Other/Unsure Emergency Contact Someone with the ability to check in on client with short notice Meals on Wheels * Meal Requirement Regular Diabetic Vegetarian Gluten Free Dairy Free * Texture Modification None Chopped Pureed Liquefied * Food Allergies Yes No * Food Sensitivity Yes No * Dislikes Yes No Consent Read Consent/Authorization for Services I hereby understand that my Personal Health Information will be a part of the Integrated Assessment Record which allows for seamless care across various health service providers. Security QuestionPlease enter an answer in digits:7 + nineteen =