Demande de rendez-vous ambulatoire

*= mandatory fields

Insurance

AVS number*

Health insurance *

Hospitalization coverage *

I have subscribed to the "family doctor" or "HMO" model of my insurance

Domain *

First name *

Name *

Birth date (dd.mm.yyyy) *

Legal address (for sending your appointment confirmation) *

Zip code *

City *

Phone number on which you are okay to be contacted *

Email address on which you are okay to be contacted *

Preferred time for calling (between 8am-12pm and 2pm-4:30pm) :

I agree with the conditions related to the transmission and privacy of the data and the rules of use that apply to an appointment request. *