Patient Detail

Identification

Please fill out the following form on behalf of the person seeking health care. Enter the information exactly as it appears on their health insurance card.

All fields are required.

Family name

Error: Last name is required

The name entered does not match the health insurance number

Given name

Error: First name is required

The first name entered does not match the health insurance number

Phone number

Enter a number with a valid area code

Please verify your area code.

Health insurance number

Enter the health insurance number of the person who requires care.

Error: The health insurance number must follow this format: YYYY 1111 1111.

I do not have a health insurance number

Sequential number

Error: The sequential number must follow this format: 01.

Date of birth

Day

Month

Year

Error: The date of birth format must be greater than 0 years.

The date of birth entered does not match the health insurance number

Postal Code

Please enter the postal code
of your home or current location.

How are available appointments displayed?

Step 1.

Availabilities in your clinic

We look for an appointment in your clinic, preferably with your healthcare professional. If that isn’t possible, we check with another professional at your clinic.

Step 2.

Openings in clinics near your postal code

We will check for available appointments at clinics near your home address, based on the postal code you provide.

How are available appointments displayed?

All fields are required.

Communication Method

How would you prefer to receive your appointment confirmation?

This email address appears to be invalid. Please check its format, for example: firstname.lastname@example.com

SMS (text message) – standard data rates may apply

Follow-up will be done at the following number:

You can always view or cancel your appointment in the “Appointments made” section.

Preferences

Select the period(s) of the day and the maximum distance. The search results will be based on availability. We cannot guarantee we will meet your exact choices.

Error: Please review your information.

I have a health need

Identification

Communication Method

Preferences