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Request For Information on Surgery

By submitting this form, you authorize the Lacroix Private Surgery team to contact you to discuss your surgical needs in greater detail and, if necessary and if you see fit, to schedule an assessment meeting with a surgeon. Note that this first consultation will allow the surgeon to determine whether or not you are eligible for surgery and does not in itself constitute a promise of surgery.

Appuyez sur Entrée

Your Name *

Prénom

Nom

Your Age *

Gender *

Man
Woman
Other

Your Phone No. *

Your Email *

In a few words, explain your need/problem (optional)

How do you prefer to be contacted? *

By Phone
By Email
Both are OK

What would be the desired location for your surgery? *

Operating Room in Laval, 1500 Montgolfier
Operating Room in Québec, 1000 Chemin Ste-Foy
Does not matter

« 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.