Request for a consultation in internal medicine

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By submitting this form, you authorize the Lacroix Private Medicine team to contact you in order to set up a consultation appointment with you. Please note that the person who will contact you by phone is not a health professional and will therefore not be able to advise you on health matters. The sole purpose of this form is to make a consultation appointment.

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Your Name *

Prénom

Nom

Your Age *

Civility *

Male
Female
Other

Phone No. *

Would you like to consult in Quebec City with Dr. Samson or in Boucherville with Dr. Audet? *

When would you like to consult? *

What need do you want to consult for? *

In a few words, explain your problem (optional)

« By submitting this form and my personal information, I consent to the use of this personal information by the Lacroix network. »

For more details on the Lacroix network's practices regarding governance of personal information, you can refer to the network's governance policy on personal information and confidentiality policy, click here.