Form

Add/update your contact information | Hôpital Fleurimont and Hôtel-Dieu de Sherbrooke

Your request (Step 1 of 4)

What do you want to do?*

I want to register for online services

I want to change my contact details

Your identity (Step 2 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 (e.g. YYYY-MM)*

Your contact details (Step 3 of 4)

Street address*

Appartment

City*

Postal Code (e.g. : J1N 0L9)*

Province*

Phone number*

Cell phone number

Work phone number (or other)

E-mail Address*

E-mail confirmation*

Choose one option:*

Keep the same e-mail address on file (the one we already have)

Add an e-mail address to your file or change the e-mail address we currently have.

Autorisations and consents (Step 4 of 4)

Autorisations*

I understand that by providing my e-mail address, I authorize the appointment center to send me information about my appointments by e-mail.

No information relating to your health (diagnosis, test results, etc.) will be sent to you by e-mail.

At the next step, you will have the opportunity to 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.

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