Physicians or parents of a child in need of a MIKEY, can apply using the form below.
If you are an organization looking to place a MIKEY at your location, please use the application here.

The Mikey Network is a registered Canadian charity, governed by rules and regulations set forth by the Canada Revenue Agency. Our charter limits us to only consider requests for a MIKEY defibrillator from residents of Canada.

Fields with (*) are required.

MIKEY Kids Physician Application

Website

Cardiologist's Name *

Cardiologist's Phone *

Affiliated Hospital *

Parent/Legal Guardian Information

Parent/Guardian #1 First Name *

Parent/Guardian #1 Last Name *

Parent/Guardian #1 Phone *

Parent/Guardian #1 Mobile *

Parent/Guardian #1 Email *

Parent/Guardian #1 Address Street *

City *

Province *

Postal Code *

Parent/Legal Guardian #2 (optional)

Parent/Guardian #2 Name

Parent/Guardian #2 Last Name

Parent/Guardian #2 Email

Child Information

Child's Name *

Child's Date of Birth (YYYY-MM-DD) *

Child's Diagnosis *

Additional Information

Is the application filled out by the child's doctor or a family member? *

By checking this box and submitting this form, you authorize The Mikey Network to contact the Physician named in this application to discuss personal medical information as it relates to this application.