{"id":3787,"date":"2021-01-12T00:06:47","date_gmt":"2021-01-12T05:06:47","guid":{"rendered":"https:\/\/healthhubsolutions.ca\/?page_id=3787"},"modified":"2026-02-02T15:51:57","modified_gmt":"2026-02-02T20:51:57","slug":"remboursement-2","status":"publish","type":"page","link":"https:\/\/healthhubsolutions.ca\/fr\/refunds\/","title":{"rendered":"Refunds"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3787\" class=\"elementor elementor-3787\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-c0e44a1 elementor-section-height-min-height elementor-section-boxed elementor-section-height-default elementor-section-items-middle\" data-id=\"c0e44a1\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[{&quot;_id&quot;:&quot;78a5b30&quot;,&quot;jet_parallax_layout_image&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;jet_parallax_layout_image_tablet&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;jet_parallax_layout_image_mobile&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;jet_parallax_layout_speed&quot;:{&quot;unit&quot;:&quot;%&quot;,&quot;size&quot;:50,&quot;sizes&quot;:[]},&quot;jet_parallax_layout_type&quot;:&quot;scroll&quot;,&quot;jet_parallax_layout_direction&quot;:&quot;1&quot;,&quot;jet_parallax_layout_fx_direction&quot;:null,&quot;jet_parallax_layout_z_index&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x&quot;:50,&quot;jet_parallax_layout_bg_x_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y&quot;:50,&quot;jet_parallax_layout_bg_y_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size&quot;:&quot;auto&quot;,&quot;jet_parallax_layout_bg_size_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_animation_prop&quot;:&quot;transform&quot;,&quot;jet_parallax_layout_on&quot;:[&quot;desktop&quot;,&quot;tablet&quot;]}],&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-d305a5f\" data-id=\"d305a5f\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-00b5d02 elementor-widget__width-initial elementor-widget elementor-widget-heading\" data-id=\"00b5d02\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Rental Refund Request Form<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-5c873e23 elementor-section-height-min-height elementor-section-boxed elementor-section-height-default elementor-section-items-middle\" data-id=\"5c873e23\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[{&quot;_id&quot;:&quot;bddedac&quot;,&quot;jet_parallax_layout_image&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;jet_parallax_layout_image_tablet&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;jet_parallax_layout_image_mobile&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;jet_parallax_layout_speed&quot;:{&quot;unit&quot;:&quot;%&quot;,&quot;size&quot;:50,&quot;sizes&quot;:[]},&quot;jet_parallax_layout_type&quot;:&quot;scroll&quot;,&quot;jet_parallax_layout_direction&quot;:&quot;1&quot;,&quot;jet_parallax_layout_fx_direction&quot;:null,&quot;jet_parallax_layout_z_index&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x&quot;:50,&quot;jet_parallax_layout_bg_x_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y&quot;:50,&quot;jet_parallax_layout_bg_y_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size&quot;:&quot;auto&quot;,&quot;jet_parallax_layout_bg_size_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_animation_prop&quot;:&quot;transform&quot;,&quot;jet_parallax_layout_on&quot;:[&quot;desktop&quot;,&quot;tablet&quot;]}],&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-66a5a50b\" data-id=\"66a5a50b\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-49f4718f elementor-widget elementor-widget-text-editor\" data-id=\"49f4718f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>HealthHub Solutions is committed to customer service and transparency. Please provide as much information as possible in the form below and allow up to 15 days for refund processing if qualified.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-59cfcaa elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"59cfcaa\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[{&quot;_id&quot;:&quot;d57a244&quot;,&quot;jet_parallax_layout_image&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;jet_parallax_layout_image_tablet&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;jet_parallax_layout_image_mobile&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;jet_parallax_layout_speed&quot;:{&quot;unit&quot;:&quot;%&quot;,&quot;size&quot;:50,&quot;sizes&quot;:[]},&quot;jet_parallax_layout_type&quot;:&quot;scroll&quot;,&quot;jet_parallax_layout_direction&quot;:&quot;1&quot;,&quot;jet_parallax_layout_fx_direction&quot;:null,&quot;jet_parallax_layout_z_index&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x&quot;:50,&quot;jet_parallax_layout_bg_x_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y&quot;:50,&quot;jet_parallax_layout_bg_y_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size&quot;:&quot;auto&quot;,&quot;jet_parallax_layout_bg_size_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_animation_prop&quot;:&quot;transform&quot;,&quot;jet_parallax_layout_on&quot;:[&quot;desktop&quot;,&quot;tablet&quot;]}],&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-0220d0e\" data-id=\"0220d0e\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-c45d1bd pp-gravity-form-button-custom pp-gravity-form-pagination-buttons-auto elementor-widget elementor-widget-pp-gravity-forms\" data-id=\"c45d1bd\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"pp-gravity-forms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"pp-contact-form pp-gravity-form\">\n\t\t\t\t\t\t\t\t\t\t<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar 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gfield_required_asterisk\">*<\/span>\u00a0\u00bb indique les champs n\u00e9cessaires<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/fr\/wp-json\/wp\/v2\/pages\/3787' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_27\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Your Rental Bed<\/h3><\/div><div id=\"field_3_26\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><section class=\"hhs-refund-bed-selection\">\n\t<div class=\"elementor-row\" style=\"display:flex\">\n\t\t<div class=\"elementor-column elementor-col-25 elementor-inner-column\">\n\t\t\t<div class=\"elementor-element elementor-widget elementor-widget-heading\" id=\"hospital-name\">\n\t\t\t\t<p class=\"elementor-heading-title\">[HOSPITAL]<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"elementor-column elementor-col-25 elementor-inner-column\">\n\t\t\t<div class=\"elementor-element elementor-widget elementor-widget-heading\" id=\"floor-name\">\n\t\t\t\t<p class=\"elementor-heading-title\">[FLOOR]<\/p>\n\t\t\t\t<p>FLOOR<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"elementor-column elementor-col-25 elementor-inner-column\">\n\t\t\t<div class=\"elementor-element elementor-widget elementor-widget-heading\" id=\"room-number\">\n\t\t\t\t<p class=\"elementor-heading-title\">[ROOM]<\/p>\n\t\t\t\t<p>ROOM<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"elementor-column elementor-col-25 elementor-inner-column\">\n\t\t\t<div class=\"elementor-element elementor-widget elementor-widget-heading\" id=\"bed-number\">\n\t\t\t\t<p class=\"elementor-heading-title\">[BED]<\/p>\n\t\t\t\t<p>BED<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"disclaimer\">\n<a class=\"raven-button\" href=\"javascript:clearTerminal();\">Change bed information<\/a>\n\t<\/div>\n<\/section><\/div><div id=\"field_3_1\" class=\"gfield gfield--type-select gfield--input-type-select hospital-selector field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_1'>Hospital Name<\/label><div class='ginput_container ginput_container_select'><select name='input_1' id='input_3_1' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please choose, or type the city\/hospital name...<\/option><option value='195' >Aberdeen Hospital (New Glasgow, Nova Scotia)<\/option><option value='27' >Alexandra Marine and General Hospital (Goderich, Ontario)<\/option><option value='1443' >Allan Blair Cancer Centre (Regina, Saskatchewan)<\/option><option value='377' >BC Women&#039;s Hospital (Vancouver, British Columbia)<\/option><option value='388' >Bethesda Hospital (Steinbach, Manitoba)<\/option><option value='13' >Brampton Civic Hospital (Brampton, Ontario)<\/option><option value='1857' >Burin Peninsula Health Care Centre (Burin, Newfoundland)<\/option><option value='177' >Cambridge Memorial Hospital (Cambridge, Ontario)<\/option><option value='170' >Cape Breton Regional Hospital (Sydney, Nova Scotia)<\/option><option value='1441' >Carbonear General Hospital (Carbonear, Newfoundland)<\/option><option value='874' >Caribou Memorial (Williams Lake, British Columbia)<\/option><option value='396' >Centre Hospitalier Magog (Magog, Quebec)<\/option><option value='421' >Centre Hospitalier R\u00e9gional de Lanaudi\u00e8re H\u00f4pital de Joliette (Saint-Charles-Borromee, Quebec)<\/option><option value='392' >Centre Hospitalier R\u00e9gional du Grand Portage (Riviere-du-Loup, Quebec)<\/option><option value='4' >Chatham Kent Health Alliance (Chatham, Ontario)<\/option><option value='87' >Collingwood General and Marine Hospital (Collingwood, Ontario)<\/option><option value='410' >Concordia Hospital (Winnipeg, Manitoba)<\/option><option value='344' >Cowichan District Regional Hospital (Duncan, British Columbia)<\/option><option value='905' >Cumberland Regional Health Care Centre (Amherst, Nova Scotia)<\/option><option value='340' >Dartmouth General Hospital (Dartmouth, Nova Scotia)<\/option><option value='387' >Dauphin Regional Health Centre (Dauphin, Manitoba)<\/option><option value='382' >Digby General Hospital (Digby, Nova Scotia)<\/option><option value='1150' >Dr. Everett Chalmers (IBT) (Fredericton, New Brunswick)<\/option><option value='150' >Dr. Everett Chalmers (Legacy) (Fredericton, New Brunswick)<\/option><option value='1438' >Dr. L. A. Miller Centre (St. John&#039;s, Newfoundland)<\/option><option value='904' >East Kootenay Regional Hospital (Cranbrook, British Columbia)<\/option><option value='1039' >Erie Shores HealthCare (Leamington, Ontario)<\/option><option value='215' >Etobicoke General Hospital (Etobicoke, Ontario)<\/option><option value='384' >Fishermen&#039;s Memorial Hospital (Lunenburg, Nova Scotia)<\/option><option value='1442' >GB Cross Hospital (Clarenville, Newfoundland)<\/option><option value='293' >Georgetown Hospital (Georgetown, Ontario)<\/option><option value='634' >Glace Bay Hospital (Glace Bay, Nova Scotia)<\/option><option value='196' >Greater Niagara General Hospital (Niagara Falls, Ontario)<\/option><option value='431' >Grey Nuns Community Hospital (Edmonton, Alberta)<\/option><option value='55' >Hamilton General (Hamilton, Ontario)<\/option><option value='354' >Hants Community Hospital (Windsor, Nova Scotia)<\/option><option value='84' >Headwaters Health Care Centre (Orangeville, Ontario)<\/option><option value='201' >Health Sciences Centre (St. Johns, Newfoundland)<\/option><option value='273' >Health Sciences North (Sudbury, Ontario)<\/option><option value='1273' >Health Sciences North W0941-W0981 (Sudbury, Ontario)<\/option><option value='429' >H\u00f4pital Cit\u00e9-De-La-Sant\u00e9 (Laval, Quebec)<\/option><option value='389' >H\u00f4pital de Granby (Granby, Quebec)<\/option><option value='997' >H\u00f4pital de Granby - CHSLD Centre Leclerc and CMBC (Granby, Quebec)<\/option><option value='420' >H\u00f4pital de St-Eustache (Saint Eustache, Quebec)<\/option><option value='426' >H\u00f4pital de Verdun (Verdun, Quebec)<\/option><option value='393' >H\u00f4pital du Sacr\u00e9-C\u0153ur (Montreal, Quebec)<\/option><option value='425' >H\u00f4pital Fleury (Montreal, Quebec)<\/option><option value='424' >H\u00f4pital Jean-Talon (Montreal, Quebec)<\/option><option value='9083' >H\u00f4pital Montfort (Ottawa, Ontario)<\/option><option value='415' >H\u00f4pital Pierre-le-Gardeur (Terrebonne, Quebec)<\/option><option value='419' >H\u00f4pital R\u00e9gional de St-J\u00e9r\u00f4me (St. Jerome, Quebec)<\/option><option value='372' >Hotel Dieu Shaver Health and Rehabilitation Centre (St. Catharines, Ontario)<\/option><option value='1034' >H\u00f4tel-Dieu Grace Healthcare (1200&#039;s, 3500&#039;s, 4500&#039;s) (Windsor, Ontario)<\/option><option value='934' >H\u00f4tel-Dieu Grace Healthcare (2200&#039;s, 3100&#039;s, 3200&#039;s) (Windsor, Ontario)<\/option><option value='9370' >Houses of Providence (Scarborough, Ontario)<\/option><option value='364' >Huntsville District Memorial Hospital Site (Huntsville, Ontario)<\/option><option value='853' >Inverness Hospital (Inverness, Nova Scotia)<\/option><option value='423' >IUCPQ (Quebec City, Quebec)<\/option><option value='412' >IUGM (Montreal, Quebec)<\/option><option value='224' >IWK Health Centre (Halifax, Nova Scotia)<\/option><option value='416' >Jewish Rehabilitation Hospital - H\u00f4pital Juif de R\u00e9adaptation (Laval, Quebec)<\/option><option value='430' >Jim Pattison Children&#039;s Hospital (Saskatoon, Saskatchewan)<\/option><option value='49' >Joseph Brant Hospital (Burlington, Ontario)<\/option><option value='151' >Kelowna General Hospital (Kelowna, British Columbia)<\/option><option value='160' >Lakeridge Health Ajax Pickering Hospital (Ajax, Ontario)<\/option><option value='102' >Lakeridge Health Bowmanville Hospital (Bowmanville, Ontario)<\/option><option value='36' >Lakeridge Health Oshawa General Hospital (Oshawa, Ontario)<\/option><option value='846' >Lakeridge Health Port Perry Hospital (Port Perry, Ontario)<\/option><option value='207' >Lakeridge Health Whitby Hospital (Whitby, Ontario)<\/option><option value='371' >London Parkwood Institute (London, Ontario)<\/option><option value='346' >Markham Stouffville Hospital (Markham, Ontario)<\/option><option value='76' >Marotta Family Hospital (St. Catharines, Ontario)<\/option><option value='381' >McMaster Children&#039;s Hospital (Hamilton, Ontario)<\/option><option value='428' >Milton District Hospital (Milton, Ontario)<\/option><option value='338' >Milton District Hospital (2N 200-223) (Milton, Ontario)<\/option><option value='422' >Mount Sinai (Floors: 10, 15, 16, 17) (Toronto, Ontario)<\/option><option value='333' >Nanaimo Regional General Hospital (Nanaimo, British Columbia)<\/option><option value='60' >Norfolk General Hospital (Simcoe, Ontario)<\/option><option value='1445' >North Bay Regional Health Centre Cartier Site (North Bay, Ontario)<\/option><option value='178' >Northside Harbor View Hospital (North Sydney, Nova Scotia)<\/option><option value='917' >Nova Scotia Rehab Centre (Halifax, Nova Scotia)<\/option><option value='435' >NTHSSA Stanton Territorial Hospital (Yellowknife, Northwest Territories)<\/option><option value='413' >Oakville Trafalgar Memorial Hospital (Oakville, Ontario)<\/option><option value='163' >Oromocto Public Hospital (Oromocto, New Brunswick)<\/option><option value='110' >Pasqua Hospital (Regina, Saskatchewan)<\/option><option value='123' >Penticton Regional Hospital (Penticton, British Columbia)<\/option><option value='120' >Prince Albert Victoria (Prince Albert, Saskatchewan)<\/option><option value='432' >Providence Care Hospital (Kingston, Ontario)<\/option><option value='8370' >Providence Healthcare (Scarborough, Ontario)<\/option><option value='361' >QE2 Halifax infirmary \/ Queen Elizabeth (Halifax, Nova Scotia)<\/option><option value='383' >Queens General Hospital (Liverpool, Nova Scotia)<\/option><option value='100' >Regina General Hospital (Regina, Saskatchewan)<\/option><option value='71' >Royal Inland Hospital (Kamloops, British Columbia)<\/option><option value='227' >Royal Jubilee Hospital (Victoria, British Columbia)<\/option><option value='285' >Royal University Hospital (Saskatoon, Saskatchewan)<\/option><option value='1216' >Saint John Regional Hospital (Saint John, New Brunswick)<\/option><option value='118' >Saskatoon City Hospital (Saskatoon, Saskatchewan)<\/option><option value='247' >Sault Area Hospital (Sault Ste. Marie, Ontario)<\/option><option value='433' >Selkirk Regional Health Centre (Selkirk, Manitoba)<\/option><option value='179' >Shuswap Lake General Hospital (Salmon Arm, British Columbia)<\/option><option value='394' >Sir Thomas Roddick Hospital (Stephenville,  NFLD)<\/option><option value='353' >Soldiers Memorial Hospital (Middleton, Nova Scotia)<\/option><option value='1839' >South Huron Hospital (Exeter, Ontario)<\/option><option value='837' >South Muskoka Memorial Hospital Site (Bracebridge, Ontario)<\/option><option value='352' >South Shore Regional Hospital (Bridgewater, Nova Scotia)<\/option><option value='349' >Southlake Regional Health Centre (Newmarket, Ontario)<\/option><option value='1094' >St. Clare&#039;s Mercy (IBT: 4E, 7E) (St. John&#039;s, Newfoundland)<\/option><option value='94' >St. Clare\u2019s Mercy Hospital (Legacy) (St. Johns, Newfoundland)<\/option><option value='865' >St. Joseph&#039;s Health Center (Guelph, Ontario)<\/option><option value='268' >St. Joseph&#039;s Healthcare (Hamilton, Ontario)<\/option><option value='1268' >St. Joseph\u2019s Healthcare - Charlton site (D4 CTU, T4122 to 4130, T7) (Hamilton, Ontario)<\/option><option value='164' >St. Martha\u2019s Regional Hospital (Antigonish, Nova Scotia)<\/option><option value='900' >St. Michael\u2019s Hospital (Floors 4 &amp; 6 Bond) (Toronto, Ontario)<\/option><option value='257' >St. Michael\u2019s Hospital (Floors 7, 8, 9, 14, 15, 16; Tower floors) (Toronto, Ontario)<\/option><option value='129' >St. Paul\u2019s Hospital (Vancouver, British Columbia)<\/option><option value='223' >St. Paul\u2019s Hospital (Saskatoon, Saskatchewan)<\/option><option value='72' >St. Thomas Elgin General Hospital (St. Thomas, Ontario)<\/option><option value='395' >Strait Richmond Hospital (Evanston, Nova Scotia)<\/option><option value='409' >Surrey Memorial Hospital Critical Care Tower (Surrey, British Columbia)<\/option><option value='855' >The Roseway Shelburne Hospital (Shelburne, Nova Scotia)<\/option><option value='3' >Thunder Bay Regional Health Sciences Centre (Thunder Bay, Ontario)<\/option><option value='289' >Timmins and District Hospital (Timmins, Ontario)<\/option><option value='875' >Toronto Grace Health Centre (Toronto, Ontario)<\/option><option value='376' >Upper River Valley Hospital (Waterville, New Brunswick)<\/option><option value='350' >Valley Regional Hospital (Kentville, Nova Scotia)<\/option><option value='79' >Vancouver General Hospital (Vancouver, British Columbia)<\/option><option value='30' >Vernon Jubilee Hospital (Vernon, British Columbia)<\/option><option value='117' >Victoria General (Halifax, Nova Scotia)<\/option><option value='154' >Victoria General (Victoria, British Columbia)<\/option><option value='272' >Welland County General Hospital (Welland, Ontario)<\/option><option value='93' >Windsor Regional Hospital - Met Campus (Windsor, Ontario)<\/option><option value='115' >Windsor Regional Hospital - Ouellette Campus (Windsor, Ontario)<\/option><option value='31' >Woodstock General Hospital (Woodstock, Ontario)<\/option><option value='202' >Yarmouth Regional Hospital (Yarmouth, Nova Scotia)<\/option><\/select><\/div><\/div><div id=\"field_3_15\" class=\"gfield gfield--type-select gfield--input-type-select gf_left_third hospital-selector gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_15'>Floor Name<\/label><div class='ginput_container ginput_container_select'><select name='input_15' id='input_3_15' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select a floor<\/option><\/select><\/div><\/div><div id=\"field_3_16\" class=\"gfield gfield--type-select gfield--input-type-select gf_middle_third hospital-selector gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_16'>Room Number<\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_3_16' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select a room<\/option><\/select><\/div><\/div><div id=\"field_3_17\" class=\"gfield gfield--type-select gfield--input-type-select gf_right_third hospital-selector gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_17'>Bed Number<\/label><div class='ginput_container ginput_container_select'><select name='input_17' id='input_3_17' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select a bed<\/option><\/select><\/div><\/div><div id=\"field_3_18\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_18' id='input_3_18' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_3_24\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_24' id='input_3_24' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_3_28\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Rental Details<\/h3><\/div><fieldset id=\"field_3_2\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Patient Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_2'>\n                            \n                            <span id='input_3_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.3' id='input_3_2_3' value=''   aria-required='true'   placeholder='Patient First Name'  \/>\n                                                    <label for='input_3_2_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Patient First Name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_3_2_6' value=''   aria-required='true'   placeholder='Patient Last Name'  \/>\n                                                    <label for='input_3_2_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Patient Last Name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_4\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_4'>Order ID<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_3_4' type='text' value='' class='medium'    placeholder='R#########' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_5\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Credit Card Holder&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_3_5'>\n                            \n                            <span id='input_3_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.3' id='input_3_5_3' value=''   aria-required='true'   placeholder='First Name &amp; Last Name'  \/>\n                                                    <label for='input_3_5_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Full Name<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><div id=\"field_3_7\" class=\"gfield gfield--type-email gfield--input-type-email gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_7'>Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_7' id='input_3_7' type='email' value='' class='medium'   placeholder='eg. name@gmail.com' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_8\" class=\"gfield gfield--type-phone gfield--input-type-phone gf_right_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_8'>Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_3_8' type='tel' value='' class='medium'  placeholder='(###) ###-####'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_13\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-custom-icon gf_left_half gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_13'>Rental Start Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_13' id='input_3_13' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_13_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_13_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_13' class='gform_hidden' value='\/wp-content\/uploads\/2021\/01\/schedule.png'\/><\/div><div id=\"field_3_6\" class=\"gfield gfield--type-select gfield--input-type-select gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_6'>Reason for Refund<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_3_6' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please choose<\/option><option value='Patient has moved to another hospital' >Patient has moved to another hospital<\/option><option value='Patient has transferred to a different room without service' >Patient has transferred to a different room without service<\/option><option value='Service issue' >Service issue<\/option><option value='Other reasons' >Other reasons<\/option><\/select><\/div><\/div><div id=\"field_3_39\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_39'>Please let us know the reason why your refund is being requested<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_3_39' type='text' value='' class='medium' maxlength='200'   placeholder='State your reason here' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_19\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p class=\"refund-note\"> Please note: If service ticket number is included in your submission, the refund is based on the date that the service issue was reported. If you do not have a service ticket number, your refund request will be based on the date that this form is submitted.<\/p><\/div><div id=\"field_3_14\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_14'>Please provide us with your service ticket #<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_3_14' type='text' value='' class='medium' maxlength='6' aria-describedby=\"gfield_description_3_14\"  placeholder='eg. 1234'  aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_3_14'>3 min characters, 6 max characters<\/div><\/div><div id=\"field_3_20\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p class=\"refund-note\">If your service issue has not yet been reported, please use this form to do so. (<a href=\"https:\/\/healthhubsolutions.ca\/service-request\/\">https:\/\/healthhubsolutions.ca\/service-request\/<\/a>) Once you have submitted the ticket, enter your service ticket ID above.<\/p><\/div><div id=\"field_3_30\" class=\"gfield gfield--type-select gfield--input-type-select field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_30'>New Hospital<\/label><div class='gfield_description' id='gfield_description_3_30'>Please let us know which hospital you have moved to, as we service many hospitals across Canada, and may be able to continue your service at your new location. <\/div><div class='ginput_container ginput_container_select'><select name='input_30' id='input_3_30' class='medium gfield_select'  aria-describedby=\"gfield_description_3_30\"   aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select an Option<\/option><option value='-1' >Other\/Unknown<\/option><option value='195' >Aberdeen Hospital (New Glasgow, Nova Scotia)<\/option><option value='27' >Alexandra Marine and General Hospital (Goderich, Ontario)<\/option><option value='1443' >Allan Blair Cancer Centre (Regina, Saskatchewan)<\/option><option value='377' >BC Women&#039;s Hospital (Vancouver, British Columbia)<\/option><option value='388' >Bethesda Hospital (Steinbach, Manitoba)<\/option><option value='13' >Brampton Civic Hospital (Brampton, Ontario)<\/option><option value='1857' >Burin Peninsula Health Care Centre (Burin, Newfoundland)<\/option><option value='177' >Cambridge Memorial Hospital (Cambridge, Ontario)<\/option><option value='170' >Cape Breton Regional Hospital (Sydney, Nova Scotia)<\/option><option value='1441' >Carbonear General Hospital (Carbonear, Newfoundland)<\/option><option value='874' >Caribou Memorial (Williams Lake, British Columbia)<\/option><option value='396' >Centre Hospitalier Magog (Magog, Quebec)<\/option><option value='421' >Centre Hospitalier R\u00e9gional de Lanaudi\u00e8re H\u00f4pital de Joliette (Saint-Charles-Borromee, Quebec)<\/option><option value='392' >Centre Hospitalier R\u00e9gional du Grand Portage (Riviere-du-Loup, Quebec)<\/option><option value='4' >Chatham Kent Health Alliance (Chatham, Ontario)<\/option><option value='87' >Collingwood General and Marine Hospital (Collingwood, Ontario)<\/option><option value='410' >Concordia Hospital (Winnipeg, Manitoba)<\/option><option value='344' >Cowichan District Regional Hospital (Duncan, British Columbia)<\/option><option value='905' >Cumberland Regional Health Care Centre (Amherst, Nova Scotia)<\/option><option value='340' >Dartmouth General Hospital (Dartmouth, Nova Scotia)<\/option><option value='387' >Dauphin Regional Health Centre (Dauphin, Manitoba)<\/option><option value='382' >Digby General Hospital (Digby, Nova Scotia)<\/option><option value='1150' >Dr. Everett Chalmers (IBT) (Fredericton, New Brunswick)<\/option><option value='150' >Dr. Everett Chalmers (Legacy) (Fredericton, New Brunswick)<\/option><option value='1438' >Dr. L. A. Miller Centre (St. John&#039;s, Newfoundland)<\/option><option value='904' >East Kootenay Regional Hospital (Cranbrook, British Columbia)<\/option><option value='1039' >Erie Shores HealthCare (Leamington, Ontario)<\/option><option value='215' >Etobicoke General Hospital (Etobicoke, Ontario)<\/option><option value='384' >Fishermen&#039;s Memorial Hospital (Lunenburg, Nova Scotia)<\/option><option value='1442' >GB Cross Hospital (Clarenville, Newfoundland)<\/option><option value='293' >Georgetown Hospital (Georgetown, Ontario)<\/option><option value='634' >Glace Bay Hospital (Glace Bay, Nova Scotia)<\/option><option value='196' >Greater Niagara General Hospital (Niagara Falls, Ontario)<\/option><option value='431' >Grey Nuns Community Hospital (Edmonton, Alberta)<\/option><option value='55' >Hamilton General (Hamilton, Ontario)<\/option><option value='354' >Hants Community Hospital (Windsor, Nova Scotia)<\/option><option value='84' >Headwaters Health Care Centre (Orangeville, Ontario)<\/option><option value='201' >Health Sciences Centre (St. Johns, Newfoundland)<\/option><option value='273' >Health Sciences North (Sudbury, Ontario)<\/option><option value='1273' >Health Sciences North W0941-W0981 (Sudbury, Ontario)<\/option><option value='429' >H\u00f4pital Cit\u00e9-De-La-Sant\u00e9 (Laval, Quebec)<\/option><option value='389' >H\u00f4pital de Granby (Granby, Quebec)<\/option><option value='997' >H\u00f4pital de Granby - CHSLD Centre Leclerc and CMBC (Granby, Quebec)<\/option><option value='420' >H\u00f4pital de St-Eustache (Saint Eustache, Quebec)<\/option><option value='426' >H\u00f4pital de Verdun (Verdun, Quebec)<\/option><option value='393' >H\u00f4pital du Sacr\u00e9-C\u0153ur (Montreal, Quebec)<\/option><option value='425' >H\u00f4pital Fleury (Montreal, Quebec)<\/option><option value='424' >H\u00f4pital Jean-Talon (Montreal, Quebec)<\/option><option value='9083' >H\u00f4pital Montfort (Ottawa, Ontario)<\/option><option value='415' >H\u00f4pital Pierre-le-Gardeur (Terrebonne, Quebec)<\/option><option value='419' >H\u00f4pital R\u00e9gional de St-J\u00e9r\u00f4me (St. Jerome, Quebec)<\/option><option value='372' >Hotel Dieu Shaver Health and Rehabilitation Centre (St. Catharines, Ontario)<\/option><option value='1034' >H\u00f4tel-Dieu Grace Healthcare (1200&#039;s, 3500&#039;s, 4500&#039;s) (Windsor, Ontario)<\/option><option value='934' >H\u00f4tel-Dieu Grace Healthcare (2200&#039;s, 3100&#039;s, 3200&#039;s) (Windsor, Ontario)<\/option><option value='9370' >Houses of Providence (Scarborough, Ontario)<\/option><option value='364' >Huntsville District Memorial Hospital Site (Huntsville, Ontario)<\/option><option value='853' >Inverness Hospital (Inverness, Nova Scotia)<\/option><option value='423' >IUCPQ (Quebec City, Quebec)<\/option><option value='412' >IUGM (Montreal, Quebec)<\/option><option value='224' >IWK Health Centre (Halifax, Nova Scotia)<\/option><option value='416' >Jewish Rehabilitation Hospital - H\u00f4pital Juif de R\u00e9adaptation (Laval, Quebec)<\/option><option value='430' >Jim Pattison Children&#039;s Hospital (Saskatoon, Saskatchewan)<\/option><option value='49' >Joseph Brant Hospital (Burlington, Ontario)<\/option><option value='151' >Kelowna General Hospital (Kelowna, British Columbia)<\/option><option value='160' >Lakeridge Health Ajax Pickering Hospital (Ajax, Ontario)<\/option><option value='102' >Lakeridge Health Bowmanville Hospital (Bowmanville, Ontario)<\/option><option value='36' >Lakeridge Health Oshawa General Hospital (Oshawa, Ontario)<\/option><option value='846' >Lakeridge Health Port Perry Hospital (Port Perry, Ontario)<\/option><option value='207' >Lakeridge Health Whitby Hospital (Whitby, Ontario)<\/option><option value='371' >London Parkwood Institute (London, Ontario)<\/option><option value='346' >Markham Stouffville Hospital (Markham, Ontario)<\/option><option value='76' >Marotta Family Hospital (St. Catharines, Ontario)<\/option><option value='381' >McMaster Children&#039;s Hospital (Hamilton, Ontario)<\/option><option value='428' >Milton District Hospital (Milton, Ontario)<\/option><option value='338' >Milton District Hospital (2N 200-223) (Milton, Ontario)<\/option><option value='422' >Mount Sinai (Floors: 10, 15, 16, 17) (Toronto, Ontario)<\/option><option value='333' >Nanaimo Regional General Hospital (Nanaimo, British Columbia)<\/option><option value='60' >Norfolk General Hospital (Simcoe, Ontario)<\/option><option value='1445' >North Bay Regional Health Centre Cartier Site (North Bay, Ontario)<\/option><option value='178' >Northside Harbor View Hospital (North Sydney, Nova Scotia)<\/option><option value='917' >Nova Scotia Rehab Centre (Halifax, Nova Scotia)<\/option><option value='435' >NTHSSA Stanton Territorial Hospital (Yellowknife, Northwest Territories)<\/option><option value='413' >Oakville Trafalgar Memorial Hospital (Oakville, Ontario)<\/option><option value='163' >Oromocto Public Hospital (Oromocto, New Brunswick)<\/option><option value='110' >Pasqua Hospital (Regina, Saskatchewan)<\/option><option value='123' >Penticton Regional Hospital (Penticton, British Columbia)<\/option><option value='120' >Prince Albert Victoria (Prince Albert, Saskatchewan)<\/option><option value='432' >Providence Care Hospital (Kingston, Ontario)<\/option><option value='8370' >Providence Healthcare (Scarborough, Ontario)<\/option><option value='361' >QE2 Halifax infirmary \/ Queen Elizabeth (Halifax, Nova Scotia)<\/option><option value='383' >Queens General Hospital (Liverpool, Nova Scotia)<\/option><option value='100' >Regina General Hospital (Regina, Saskatchewan)<\/option><option value='71' >Royal Inland Hospital (Kamloops, British Columbia)<\/option><option value='227' >Royal Jubilee Hospital (Victoria, British Columbia)<\/option><option value='285' >Royal University Hospital (Saskatoon, Saskatchewan)<\/option><option value='1216' >Saint John Regional Hospital (Saint John, New Brunswick)<\/option><option value='118' >Saskatoon City Hospital (Saskatoon, Saskatchewan)<\/option><option value='247' >Sault Area Hospital (Sault Ste. Marie, Ontario)<\/option><option value='433' >Selkirk Regional Health Centre (Selkirk, Manitoba)<\/option><option value='179' >Shuswap Lake General Hospital (Salmon Arm, British Columbia)<\/option><option value='394' >Sir Thomas Roddick Hospital (Stephenville,  NFLD)<\/option><option value='353' >Soldiers Memorial Hospital (Middleton, Nova Scotia)<\/option><option value='1839' >South Huron Hospital (Exeter, Ontario)<\/option><option value='837' >South Muskoka Memorial Hospital Site (Bracebridge, Ontario)<\/option><option value='352' >South Shore Regional Hospital (Bridgewater, Nova Scotia)<\/option><option value='349' >Southlake Regional Health Centre (Newmarket, Ontario)<\/option><option value='1094' >St. Clare&#039;s Mercy (IBT: 4E, 7E) (St. John&#039;s, Newfoundland)<\/option><option value='94' >St. Clare\u2019s Mercy Hospital (Legacy) (St. Johns, Newfoundland)<\/option><option value='865' >St. Joseph&#039;s Health Center (Guelph, Ontario)<\/option><option value='268' >St. Joseph&#039;s Healthcare (Hamilton, Ontario)<\/option><option value='1268' >St. Joseph\u2019s Healthcare - Charlton site (D4 CTU, T4122 to 4130, T7) (Hamilton, Ontario)<\/option><option value='164' >St. Martha\u2019s Regional Hospital (Antigonish, Nova Scotia)<\/option><option value='900' >St. Michael\u2019s Hospital (Floors 4 &amp; 6 Bond) (Toronto, Ontario)<\/option><option value='257' >St. Michael\u2019s Hospital (Floors 7, 8, 9, 14, 15, 16; Tower floors) (Toronto, Ontario)<\/option><option value='129' >St. Paul\u2019s Hospital (Vancouver, British Columbia)<\/option><option value='223' >St. Paul\u2019s Hospital (Saskatoon, Saskatchewan)<\/option><option value='72' >St. Thomas Elgin General Hospital (St. Thomas, Ontario)<\/option><option value='395' >Strait Richmond Hospital (Evanston, Nova Scotia)<\/option><option value='409' >Surrey Memorial Hospital Critical Care Tower (Surrey, British Columbia)<\/option><option value='855' >The Roseway Shelburne Hospital (Shelburne, Nova Scotia)<\/option><option value='3' >Thunder Bay Regional Health Sciences Centre (Thunder Bay, Ontario)<\/option><option value='289' >Timmins and District Hospital (Timmins, Ontario)<\/option><option value='875' >Toronto Grace Health Centre (Toronto, Ontario)<\/option><option value='376' >Upper River Valley Hospital (Waterville, New Brunswick)<\/option><option value='350' >Valley Regional Hospital (Kentville, Nova Scotia)<\/option><option value='79' >Vancouver General Hospital (Vancouver, British Columbia)<\/option><option value='30' >Vernon Jubilee Hospital (Vernon, British Columbia)<\/option><option value='117' >Victoria General (Halifax, Nova Scotia)<\/option><option value='154' >Victoria General (Victoria, British Columbia)<\/option><option value='272' >Welland County General Hospital (Welland, Ontario)<\/option><option value='93' >Windsor Regional Hospital - Met Campus (Windsor, Ontario)<\/option><option value='115' >Windsor Regional Hospital - Ouellette Campus (Windsor, Ontario)<\/option><option value='31' >Woodstock General Hospital (Woodstock, Ontario)<\/option><option value='202' >Yarmouth Regional Hospital (Yarmouth, Nova Scotia)<\/option><\/select><\/div><\/div><div id=\"field_3_35\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Please provide us with your new room or select \"Other\" if you do not see the option in the list.<\/div><div id=\"field_3_33\" class=\"gfield gfield--type-select gfield--input-type-select gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_33'>New Floor<span class=\"gfield_required\"><span class=\"gfield_required 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aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select an Option<\/option><option value='0' >Other\/Unknown<\/option><\/select><\/div><\/div><div id=\"field_3_36\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_36' id='input_3_36' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_3_37\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_37' id='input_3_37' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_3_23\" 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