Appointment form

To make an appointment, call 450-923-0055 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

Make an Appointment

Appointment date: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    january february march april may june july augustt september october november december    Year :

Preferred time of day for appointment :  morning afternoon evening anytime

Please confirm my appointment by : e-mail (telephone) home (telephone) work

Comments, questions?

Personal information

First name :*
Last name :*
Gender :	F     M
Age :
Address :*
City :*
Postal code :*
Home (telephone) :*
Work (telephone) :*	Ext :
E-mail :

 

Thank you for taking the time to complete this form. We are looking forward to meeting you.