Website Client Intake Form

Name*
Email*
john@domain.com
Phone Number*
Please enter a valid phone number.
Type of appointment*
Is the service for a child under 14yr?
RAMQ or Health ID#
Indicate your expiary date at the end. EX: SELP92032617 09/29
Select your insurance type

Private or Group InsuranceCCQ - Construction MédicRAMQ / Medicare onlyRefugee (IFHP)
Do you already have your doctor's requisition?

Yes, I will upload it belowYes, I will upload it laterNo, I need to consult with a doctor
Are you currently experiencing any symptoms?

No current symptomsRoutine STD/STI check-up (no symptoms)Painful UrinationDischarge (genital region)Pain (genital region)Bleeding (genital region)Vaginal DrynessOpen Sores (genital region)OtherOther
Select your Location*
Select your Location Virtual*
Select your Clinic*
Address*

Street Address

Street Address Line 2
CityProvincePostal
Sex

MaleFemale
Current Symptoms (if applicable)

Heart disease (e.g., heart attack, angina, heart failure)Hypertension (high blood pressure)Diabetes (type 1 or type 2)Respiratory disease (e.g., asthma, COPD)Liver diseaseKidney diseaseCancer or tumorMental illness (e.g., depression, anxiety)Other chronic illness (please specify)Other
Are you currently taking any medication?

YesNo
Do you have any allergies to medication?

YesNo
Do you use any tobacco or nicotine products?

YesNo
Are you currently taking any non-prescription medication or using recreational drugs?

YesNo
How many alcoholic beverages do you consume in the average week?
Please indicate the average consumption
DDO Clinic - Appointment Date and Time*
Laval Clinic - Appointment Date and Time*
Downtown Montreal Clinic - Appointment Date and Time*
Sherbrooke, QC Clinic - Appointment Date and Time*
Virtual - Appointment Date and Time*
Mobile - Rapids- Appointment Date and Time*
Mobile - Blood Tests - Appointment Date and Time*
Doctor's Calendar - Appointment Date and Time
PAB / At-Home - Extended Care Appointment Date and Time
Your pharmacy address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Fax Number
Please enter their fax number so we can send a prescription to them if necessary
Upload Document or Requisition

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Communication Language*

EnglishFrench
Notes: Anything we should know about you, or your appointment request
UTM Source
UTM Campaign
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