Form

Indicate the Period When You Are Unavailable for an Appointment | Hôpital Fleurimont and Hôtel-Dieu de Sherbrooke

Important

If there are less than 48 hours before your appointment, contact us at 1 866 638-2601 (toll free).

Your identity (Step 1 of 4)

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 (YYYY-MM-DD)*

Your contact details (Step 2 of 4)

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.

Period(s) when you are unavailable for an appointment (Step 3 of 4)

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

Period 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.

You will receive a new appointment date. Please note that in accordance with MSSS regulations, your name will be removed from the waiting list after the third (3^rd) postponement or after 2 unexplained absences. Requesting to reschedule on the same day as your appointment will be considered an absence because such short notice does not give the appointment centre sufficient time to assign your time slot to another patient.

Submit (Step 4 of 4)

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.