Take care of your health now!

Name:*

Date of birth:*

Where I live (region):

Des Sources

Coaticook

Granit

Haut-Saint-François

Haute-Yamaska

La Pommeraie

Memphrémagog

Sherbrooke

Val-Saint-François

Main phone number:*

Other phone number:

Email:*

E-mail address confirmation*

I have a family doctor:

Yes

Name of family doctor:

Name of my clinic (family medicine group):

I am available (when to reach me):

Day

Evening

I prefer taking English workshops:

Yes

The reason of my interest:

Don't fill this field!

* Field is mandatory.