Form

Obtaining information concerning a request or a follow-up appointment | CSSS de Memphrémagog et CSSS du Granit

Hospital concerned

Indicate the hospital where your consultation is scheduled

CSSS de Memphrémagog

CSSS du Granit

I don't know

Your identity (Step 1 of 6)

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)*

Your contact information (Step 2 of 6)

Provide your e-mail address*

E-mail address confirmation*

Authorization to communicate with you by e-mail*

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.

Information concerning the planned appointment or for an upcomming appointment (Step 3 of 6)

Specialty (if known)*

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.

Can't find the specialty you're looking for? Can't find your 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.

Specialist's name (if known)

Appointment date (if known)

Appointment location

Informations about your request (Step 4 of 6)

Please write a brief message concerning your request for a follow-up.*

The appointment center will call you between 8:00 a.m. and 6:00 p.m. Monday through Friday. If you do not answer, we will leave a message on your voice mail.

Please indicate the phone number where you may be contacted*

For a new consultation request only (Step 5 of 6)

If necessary, would you be willing to travel to another city for a NEW appointment?

Yes

If yes, please check the city(ies) you are willing to travel to:

Cowansville

Granby

Lac Mégantic

Magog

Sherbrooke

Submit (Step 6 of 6)

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.

Transmission of data online | Confidentiality

No personal data is permanently stored on our servers.

When you provide your information through the secure forms of an appointment center, the information is sent through an electronic messaging system (e-mail) and may involve confidentiality risks.

The CIUSSS de l'Estrie – CHUS cannot guarantee the confidentiality of information transmitted by e-mail.