I have a family doctor at the clinic

Name*
As it appears on your card of the Régie de l'Assurance Maladie du Québec (RAMQ)
First Name Last Name
Date of birth*
Age
Phone*
Phone number to reach you
Extension
Extension number (if needed)
Name of your family doctor
To make an appointment, you must be a registered patient of the clinic. Otherwise, please note that you will not receive any response to your appointment request.
Person who is to be contacted
The name of the person who is to be contacted (if different from the patient)
Do you have a valid RAMQ card?*
- yes
- no
Email*
Please enter your email Please confirm your email
If you do not provide a valid RAMQ card number, you will need to pay for the consultation.
RAMQ card number*
No space please (ex. GUAL71012115)
Expiration date*
No space please (format AAAAMM)