Type of consultation (select both if both work for you) *

TELEHEALTH

HOME VISIT

Name of the patient

(if this is for a minor, sharing this information can be sensitive - you can therefore write your own name if you prefer and give the minor's name over the phone. Otherwise, rest assured your/their privacy and data protection is a priority)

First Name

Last Name

Name of the person to contact *

First Name

Last Name

Phone *

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Consent to share this personal information

This is different from consenting to the services.

I accept to share this information with MARIE-ANNICK BELIVEAU M.SC. PHT C/NDT