Québec Medical Appointment Scheduler

Identification

First name

Last name

Health insurance number

Health insurance card sequential number

Home NumberMobile Number

Date of birth (day/month/year)

Sex Male Female

I have read and accept the Terms of use. I have also read the Patient consent and I consent to the use and disclosure of my personal information by the Régie de l’assurance maladie du Québec, medical clinics, and physicians, if applicable.