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At-Home Consultation Form

Step 1 of 5

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1. Have you used our service before?
Have you used our service before?*
- Yes
- No
Fees start at $150 and vary depending on our nurses' and doctors' travel time. Private service, not covered by RAMQ.

2. Do you have any of the following medical conditions?
Do you have any of the following medical conditions?*
- Diabetes
- High blood pressure
- High cholesterol
- Respiratory disease
- Cognitive difficulty
- Mental health issues
- Require palliative care
- Other
- None of the above
In a few words, please tell us why you would like to see the doctor.
Reason for Appointment*

4. Who is the medical house call for?
Who is the medical house call for?*
- Me
- Someone else
Please provide your information for consent:
Name*
First Last
Phone*
Relationship to the patient:*

4. What is the address for the house call?
Please note that we only service the Montreal and surrounding areas*
Street Address Address Line 2 City Province Postal Code

5. Lastly, please provide more information about the person requiring the medical house call.
Name*
First Last
Date of Birth:*
Date Format: DD slash MM slash YYYY
RAMQ health card number (optional):
Phone Number:*
Email:*