Form

Cancelling your appointment or your request for an appointment

To cancel an appointment at a collection center or vaccination center, go to clicsanté

Your identity (Step 1 of 5)

First Name*

Last Name*

Father's first name*

Father's last name*

Health insurance number*

Health insurance card's Expiry date (YYYY-MM-DD)*

Your contact details (Step 2 of 5)

Address*

Appartement number

City*

Province or territory*

Postal code*

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.

Appointment to cancel information (Step 3 of 5)

Choose your situation*

I want to cancel my appointment request (I do not have an appointment date)

I want to cancel my appointment (I have an appointment date)

If you cancel a consultation: Your request will be withdrawn from the waiting list and a new request will be required from your referring Doctor.

If you cancel a follow-up appointment: Your request will be withdrawn from the waiting list. There will be a 2 year delay period, from the date of your last consultation, if you wish to consult with your specialist. After 2 years, a new request will be required from you referring Doctor.

Don't want to cancel your appointment? Return to the online services page >

Reason for cancellation*

Your appointment is no longer necessary

You have an appointment somewhere else

Other

If you chose "Other", please specify ...

Specialty*

Name of Physician

Appointment Date (if known) (YYYY-MM-DD)

Time of Appointment (if known)

Your referrer (Step 4 of 5)

Referrer

Clinic or hospital where the referrer works

Authorizations and consents (Step 5 of 5)

À la prochaine étape, vous aurez la possibilité de valider vos informations avant de nous soumettre votre demande.

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.