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Your name *

Your age *

Gender *

Man
Female
Other

Phone number *

Email address *

visit? words, number

What is your postal code? *

What is the main reason for your visit?

General consultation / Acute health issue (e.g., fever, pain, infection, recent symptoms)
Routine medical follow-up / Annual health checkup
Chronic disease follow-up (e.g., diabetes, hypertension, cholesterol, asthma, etc.)
Mental health / Psychological follow-up or anxiety (ou Mental health / Counseling or anxiety)
Prescription renewal / Refills
Medical form / Certificate / Administrative report to complete
Pediatrics / Child development follow-up
Men's and women's health (menopause and andropause)
Minor surgery / Wound care / Stitch removal
Vaccination
Urology / Gynecology
Other

In a few words, please describe your chief complaint *

« By submitting this electronic form, I understand that the information collected in this form is used solely by authorized personnel for the purpose of scheduling specialized medicine appointments and organizing the consultation, and is not used to obtain medical advice or establish a diagnosis. I consent to the use of this personal information by Lacroix Private Medicine for this purpose. »

For more information on how Lacroix Private Medicine protects your personal information, please view our Personal Information Governance Policy and Privacy Policy here.