Request an appointment

Select appointment type

Type de patient*

New patient
miacleo patient follow-up
Samples and imaging
Other

Specify*

Add a doctor's referral (if applicable)

ADD A DOCTOR'S REFERENCE (PDF, JPG)

Accepted file types: pdf, jpg, Max. file size: 20 MB.

fill in your details

Full name*

Email*

Telephone*

To register on our waiting list, please complete the form below. At present, we no longer require a referral to book an appointment. However, if your doctor has given you a referral paper, please attach it to your registration e-mail using the download button above. Please note that if you or your partner do not have a health insurance card, the consultation fee is $400 (taxes included) and the follow-up fee is $100 (taxes included).

Are you currently undergoing FERTILITY treatment at a clinic, hospital or other? (diabetes, pre-eclampsia, hypertension, etc.).*

Yes
No

Where?*

Do you have a prescription protocol? (Complete file)*

yes
no

protocol type*

Insemination
In vitro fertilization (IVF)

Where?*

patient information

Full name*

Date of birth*

Do you have a health insurance card?*

Yes
No

health insurance number*

expiration date*

Your full address*

Address Address line 2 City Province Postal code

name of your pharmacist*

complete pharmacy address*

Home telephone*

cellular*

Email*

Marital status (common-law, married or single)*

Common-law
Married
Single

full name of emergency contact person*

emergency telephone*

attachment to you*

informations du partenaire

Partner's full name

Partner's date of birth

Does your partner have a health insurance card?*

Yes
No

partner's health insurance number*

expiration date*

partner's full address

name of partner pharmacist

complete pharmacy address

partner's home telephone

partner's cellular

Partner's e-mail