Identification

First name

Last name

Health insurance number

Health insurance card sequential number

Home NumberMobile Number

Date of birth (day/month/year)

I agree that:

the Régie de l'assurance maladie du Québec communicates my personal information and, if applicable, information relating to my treating professional with medical clinics and health professionals so that my request for an appointment can be processed
the medical clinics and health professionals store and use my personal information to improve the services related to the management of my appointment requests.

Personal information collected in the Québec Medical Appointment Scheduler is protected under the Privacy policy

of the Régie de l'assurance maladie du Québec.