At-Home Consultation Form
Step 1 of 5
1. Have you used our service before?
Have you used our service before?
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?
High blood pressure
Mental health issues
Require palliative care
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?
Please provide your information for consent:
Relationship to the patient:
4. What is the address for the house call?
Please note that we only service the Montreal and surrounding areas
Address Line 2
Newfoundland and Labrador
Prince Edward Island
5. Lastly, please provide more information about the person requiring the medical house call.
Date of Birth:
Date Format: DD slash MM slash YYYY
RAMQ health card number (optional):