Thank you for your interest in our clinic for the evaluation of Dupuytren's disease.

This form allows us to gather the information needed to review your case and determine whether you may be a candidate for a diagnostic evaluation with Dr. Jean-Paul Brutus and, when appropriate, for a Percutaneous Needle Aponeurotomy (PNA).

All information you submit is transmitted through a secure, encrypted, HIPAA-compliant platform and will be kept strictly confidential.

If you prefer not to upload your medical records, imaging reports, or other supporting documents at this stage, that is completely fine. While these documents may help us assess your case more efficiently, they are optional and can be provided later if needed.

Please note that submitting this form does not guarantee an appointment.

After reviewing your information, we will contact you to let you know whether:

• you may be offered a diagnostic evaluation with Dr. Brutus;
• additional information or documentation is required to complete the assessment of your case; or
• your condition would be better managed by another specialist or with a different treatment approach, in which case we will direct you to the most appropriate resources whenever possible.

Thank you for taking the time to complete this form. We look forward to reviewing your submission.

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Professional Fees (Non-Insured Services)

We are a private clinic (non-participating with RAMQ). As such, all fees are not covered or reimbursed by the Régie de l’assurance maladie du Québec (RAMQ).

• Independent medical evaluation + detailed report provided to the patient: $975
  (Tax-deductible; not covered by RAMQ)
• Minimally invasive percutaneous treatment for Dupuytren’s disease: starting at $5000
  (Non-insured procedure – the physician does not participate in RAMQ)
  Additional fees apply for each additional finger.

Please note: 

• The evaluation is a separate service and is not applied toward the cost of treatment
  The evaluation provides an objective and personalized assessment, with no obligation to proceed with treatment
• The final treatment cost is determined following a complete evaluation of your condition

For procedures, additional fees for clinical environment and medical supplies apply where indicated (clinical environment: $200 + medical supplies: $50).

All fees are tax-deductible, but not reimbursed by RAMQ.

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Cancellation & No-Show Policy

Missed medical evaluation: $200
Missed procedure: $250

A minimum of 48 business hours' notice is required for any appointment cancellation or rescheduling. Failure to provide sufficient notice will result in the applicable missed appointment fee being charged.
* exception: genuine emergencies only.

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Required Photos (mandatory)

Please attach two (2) clear photos of the affected hand:

1) hand open, palm facing the camera
2) hand flat on a surface, palm facing down