Making or cancelling an appointment

Who is your family doctor ?

Dr Alexandre Beauchamps Dre Isabelle Boulanger Dre Véronique Bray Dre Amélie Cardinal-Houde Dr Patrick Charland Dre Hélène Daoust Dr Gaétan Drolet Dre Virginie Dubuc Dr Sylvain Dufresne Dre Josiane Gagnon Dr Yves Gagnon Dre Caroline Guay Dre Stéphanie Lalande Dr Marie-Pier Lamarre-Séguin Dr Christian Leduc Dre Maude Leroux Dr Richard Lussier Dre Sophie Maurice Dre Mariloue Parent Dre Josée Pedneault Dre Emmanuelle Poirier Dre Valérie Pomerleau Dre Alexandra Proulx Dre Manon St-Amant Dr Francis Turcot Dr Matthieu Vincent Pédiatre Dr. Lanctot Infirmière GMF Kinésiothérapeute Nutritionniste Travailleuse sociale (Ly-Ann Houle P. ou Alexandra Dubé) Prise de sang

What is your name? (Or the patient's name, if you are filling it for someone else)

What is your phone number? Be sure that you are easily reachable at that phone number.

If you NEED TO SEE YOUR PHYSICIAN; please indicate the level of emergency.
Simple URGENT need ; Absolutely Within 2 days Semi-urgent ; Within 2 weeks Non-urgent ; Within 2 months I don't know

To CANCEL AN APPOINTMENT, please indicate the date and with whom this appointment was.

THIS FORM IS ONLY FOR THE MEDICAL CENTER PATIENTS, ALL OTHER PATIENTS WON'T BE CALLED.
I understand

What is your name?

What is your phone number?

What is the date of the appointment you want to cancel for good?