Post-Treatment Care at Home

Patient Zone • Appointment form

To make an appointment, call (514) 731-4077 or follow the procedure below.

To make an appointment on line:

• Choose the day and time that are convenient to you
• Give us your complete contact information
• Fill out the form to open a medical file if this is your first visit

We will call or e-mail you within 24 hours to confirm your appointment or offer you another date and time.

Make an Appointment
Appointment date: Year: 
Preferred time of day for appointment: 
Please confirm my appointment by:
email (telephone) home (telephone) home
Comments, questions?

Personnal information:
First name:*
Last name:*
Gender: 
F  M   Age: 
Adress:*
  City:*    Postal code:* 
Home (telephone):*
Work (telephone):*
 ext: 
E-mail:

Thank you for taking the time filling in this form. We are looking forward meeting you on your next meeting.

5512 Cote-Des-Neiges #203, Montreal, Qc, H3T 1Y9 | Tel. (514) 731-4077

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