Form

Rescheduling or Postponing an Appointment | CSSS de Memphrémagog and CSSS du Granit

Hospital concerned

Indicate the hospital where your consultation is scheduled

CSSS de Memphrémagog

CSSS du Granit

I don't know

Important

If you have less than 48 hours before your appointment, please contact the relevant head office by telephone.

CSSS de Memphrémagog: 819-843-3381, ext. 2236, option 3

CSSS du Granit: 819-583-0330, ext. 36945

Your identity (Step 1 of 5)

First Name*

Last Name*

Date of birth*

Father's first name*

Father's last name*

Health insurance number (e.g.: BOUF 0000 0000)*

Health insurance card's Expiry date (e.g.: 2028-09)*

Phone (XXX-XXX-XXXX)*

E-mail*

Email confirmation*

Information about the actual Appointment (Step 2 of 5)

Specialty*

Available specialties : Anesthesia, sleep apnea, cardiology, general surgery, minor surgery, pain clinic, dermatology, ECG - Holter or MAPA, cardiac ultrasound and treadmill, endocrinology, endoscopy, gastroenterology, gynecology, internal medicine, nephrology, neurology, ophthalmology, orthopedics, otolaryngology (ENT), pediatrics, respiratory physiology (or respiratory function), pneumology.

You cannot find the specialty in this list?Then your request, type of examination (e.g. radiology) or specialized clinic (e.g. metabolic clinic) is NOT covered by this appointment center. To find the appointment center in question and its telephone number,

Name of Physician (if known)

Appointment Date*

Period when you are unavailable for an appointment (Step 3 of 5)

You have the possibility to indicate two periods of non-availability.

Période 1

FIRST DAY of period during which you will be unavailable.

FINAL DAY of period during which you will be unavailable.

Periode 2 (if necessary)

FIRST DAY of period during which you will be unavailable

LAST DAY of period during which you will be unavailable

IMPORTANT : If you already have an appointment scheduled during the period you will be unavailable, it will be rescheduled.

Authorization to reschedule an appointment and consent (Step 4 of 5)

Authorization to reschedule your appointment. Check both boxes.*

I understand that by rescheduling my appointment, I am hereby authorizing the appointment centre to schedule another appointment soon if a time slot becomes available. Otherwise, I will once again be registered on the waiting list until a time slot becomes is available.

I also understand that in accordance with MSSS regulations, my name will be removed from the waiting list after the third postponement/refusal or at the second unexplained absence, and that making a request to postpone or reschedule the same day as my appointment will be considered an absence because such short notice does not give the appointment centre sufficient time to assign my time slot to another patient.

Authorization to communicate with you by email*

I understand that by providing my e-mail address, I am hereby authorizing the appointment centre to e-mail me information concerning my appointments at the e-mail address which I have provided.

No information concerning your health status (diagnosis, test results, etc.) will be e-mailed to you.

Submit (Step 5 of 5)

In the next step, you will be given the opportunity to confirm and validate your information before submitting your request.

Don't fill this field!

* Field is mandatory.