Disability Tax Credit Form - ADHD Centre for Women

Disability Tax Credit

Step 1 of 4

Have you had an Adult ADHD Assessment completed at the Adult ADHD Centre?(Required)

Yes

Patient Name(Required)

First Last

Patient Email(Required)

Patient Date of Birth(Required)

Patient Phone(Required)

Patient Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Billing Info Same as Patient

Payer Name(Required)

First Last

Phone(Required)

Payer Email(Required)

Payer Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country