Chargement...

Request for an Appointment in Neurosurgery

By submitting this form, you authorize the Lacroix Médecine Privée team to contact you in order to set up a consultation appointment with you. Note that the person who will contact you on the phone is not a health professional and therefore cannot advise you on health matters. This form is for the sole purpose of making an appointment for consultation.

Appuyez sur Entrée

Your Name *

Prénom

Nom

Your Age *

Gender *

Man
Woman
Other

Your Phone No. *

Your Email

In which region would you like to consult in neurosurgery? *

Note that it may happen that a doctor meets patients in a region other than his usual region. Dr. Martel, for example, sometimes travels to Boucherville. Surgeries are performed in our operating rooms in Quebec City and Laval.

When would you like to consult? *

For what need do you want to consult? *

Have your problem already been diagnosed by a doctor? *

In a few words, describe your problem (optionnal)

« 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 governance policy on personal information and the network's confidentiality policy by clicking here.