<form-template> <fields> <field type="paragraph" subtype="p" label="The Town of Wembley Council had been diligently working on reopening the Wembley Medical Clinic. The following survey is to assist us in our efforts." class="paragraph"></field> <field type="select" required="true" label="1. DO YOU CURRENTLY HAVE A FAMILY PHYSICIAN/NURSE PRACTITIONER?" class="form-control select" name="select-1753910708118"> <option value="CLICK DOWN TO SELECT" selected="true">CLICK DOWN TO SELECT</option> <option value="YES">YES</option> <option value="NO">NO</option> </field> <field type="select" required="true" label="2. ARE THERE ANY OTHER INDIVIDUALS (INCLUDING CHILDREN) IN YOUR HOUSEHOLD WHO DO NOT HAVE A FAMILY PHYSICIAN/NURSE PRACTITIONER?" class="form-control select" name="select-1753820973959"> <option value="CLICK DOWN TO SELECT" selected="true">CLICK DOWN TO SELECT</option> <option value="NONE">NONE</option> <option value="1">1</option> <option value="2">2</option> <option value="3">3</option> <option value="4">4</option> <option value="5 OR MORE">5 OR MORE</option> </field> <field type="select" required="true" label="3. WHICH MUNICIPALITY DO YOU CURRENTLY RESIDE IN?" class="form-control select" name="select-1753911006634"> <option value="CLICK DOWN TO SELECT" selected="true">CLICK DOWN TO SELECT</option> <option value="TOWN OF WEMBLEY">TOWN OF WEMBLEY</option> <option value="TOWN OF BEAVERLODGE">TOWN OF BEAVERLODGE</option> <option value="TOWN OF SEXSMITH">TOWN OF SEXSMITH</option> <option value="COUNTY OF GRANDE PRAIRIE">COUNTY OF GRANDE PRAIRIE</option> <option value="CITY OF GRANDE PRAIRIE">CITY OF GRANDE PRAIRIE</option> <option value="OTHER">OTHER</option> </field> <field type="checkbox-group" required="true" label="4. WHAT OTHER SERVICES WOULD YOU LIKE TO SEE IN THE WEMBLEY MEDICAL CLINIC? You may select more than one option and add other services not listed." class="checkbox-group" name="checkbox-group-1753912842477" enable-other="true" other="true"> <option value="A. ADDICTION AND MENTAL HEALTH SERVICES">A. ADDICTION AND MENTAL HEALTH SERVICES</option> <option value="B. CARDIAC MONITORING SERVICES">B. CARDIAC MONITORING SERVICES</option> <option value="C. CHILD, YOUTH, SENIORS AND FAMILY MENTAL HEALTH THERAPY">C. CHILD, YOUTH, SENIORS AND FAMILY MENTAL HEALTH THERAPY</option> <option value="D. LABORATORY SERVICES">D. LABORATORY SERVICES</option> <option value="E. OCCUPATIONAL THERAPY">E. OCCUPATIONAL THERAPY</option> <option value="F. PHYSIOTHERAPY">F. PHYSIOTHERAPY</option> <option value="G. RESPIRATORY THERAPY">G. RESPIRATORY THERAPY</option> <option value="H. TRANSITION SERVICES CONTINUING CARE COUNSELLORS AND SOCIAL WORKERS">H. TRANSITION SERVICES CONTINUING CARE COUNSELLORS AND SOCIAL WORKERS</option> </field> <field type="text" subtype="email" label="EMAIL (OPTIONAL)" class="form-control text-input" name="text-1753911518254"></field> <field type="paragraph" subtype="p" label="For questions, please send an email to: info@wembley.ca Attention: Noreen Zhang, CAO" class="paragraph"></field> <field type="text" subtype="text" label=" PLEASE NOTE: The personal information on this form is being collected in accordance with Section 33(c) of the Freedom of Information and Protection of Privacy Act (FOIP Act) RSA 2000 CF-23. If you have any questions about the collection, use and protection of this information, please contact the Town of Wembley FOIP Coordinator at 780-766-2269 or info@wembley.ca. " class="form-control text-input" name="text-1753913649326"></field> </fields> </form-template> Submit Submitting...