KixCare

1
Please select availability* This field is required.Now also available on Bonjour Santé !
2
Hubspot Source
3
Get Page URL
4
How can we help?Can't find what you're looking for? Just select 'Other'
5
In 2-3 sentences, please describe your reason for visit.* This field is required.We care about your child. Please note that there are some conditions that are difficult to assess virtually (ex: ear pain, pneumonia, vaccination administration and routine check ups). Some conditions may be redirected for an in-person visit. Please visit our website for a detailed list of conditions that may be difficult to assess virtually.
Huge
Large
Normal
Small
Ok
Ok
6
Parent Information* This field is required.
Parent Name
Mother
Father
Sister
Brother
Grandparent
Guardian
Other
Relationship to child
Email
Phone
Street Address
Postal
City
Quebec
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
7
Child's Information* This field is required.
Child's First Name
Child's Last Name
Date of birth (YYYY/MM/DD)
Female
Male
Other
Gender
No - it's the first time for this child at KixCare
Yes - this child has been at KixCare before
No - it's the first time for this child at KixCare
Have you been seen here before?
8
Current Date
Date
Year
Month
Day
9
Patient Birthday
Date
Year
Month
Day
10
Patient Age
11
Unfortunately, KixCare pediatricians can only see patients ages 0-17. Malheureusement, nos pédiatres chez KixCare peuvent seulement voir les patients de moins de 18 ans.
12
Does your child have a valid RAMQ card?If your child is under the age of 1 and/or has yet to receive their RAMQ, please enter the RAMQ number of the legal guardian.
Yes, Use RAMQNo, Pay via Credit Card
13
Thank you for choosing KixCare. Please note that if you do not have a valid health card, you will be charged for the consultation and an invoice will be provided following the visit. A member of our team will reach out to you prior to your appointment to collect Credit Card details.

Prices for consultations may vary between $60-$125.
14
RAMQ Information* This field is required.If your child is under the age of 1 and/or has yet to receive their RAMQ, please enter the RAMQ number of the legal guardian.
RAMQ Number
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
Expiry Year
January
February
March
April
May
June
July
August
September
October
November
December
Expiry Month
15
Help us improve your visit by providing the following information.This information will be used by your provider to send prescriptions and keep your family doctor in the loop, if applicable.
Patient Weight
lb
lb
kg
Unit
Preferred Pharmacy Full Address
Pharmacy Fax Number
Pediatrician / Family Doctor Name and Phone Number
Allergies
Active Medication
16
Our Privacy Policy and Terms of Use* This field is required.
By selecting this, you agree to the Privacy Policy and Terms of Use.
By selecting this, you agree to receive marketing communication.
17
Thank you for your interest but at the moment we are not currently offering services in your area. Please do sign up for our newsletter to stay informed of when we will.
18
View uploaded photo submission
19
Send patient link to:
example@example.com
20
Tags
Todo
In Progress
Done
Should be Empty: