Partial copy of the file

Q: Partial copy of the file

[gravityform id="47" title="false" description="false"]

Q: Partial copy of the file

[gravityform id="47" title="false" description="false"]

Q: Partial copy of the file

[gravityform id="47" title="false" description="false"]

Once your request below is completed, we will be happy to respond to your request within 15 business days.

The partial copy of the file is not a service covered by Medicare. Therefore, fees apply, based on the Federation of Physicians' fee scale.

Please remember to check your ''spam'' or ''junk'' folder if you do not receive a response from us within 15 business days.

Identification*
First Last

Email*
Email Confirm Email

Phone*

Date of birth*
AAAA slash MM slash JJ

Health Insurance Number (RAMQ)*
(No spaces)

Which documents in your file would you like a copy of?*

Fee for partial copy of the file
Prix:

Transmission mode*

I will pick up the documents at the clinic once you notify me that it is ready (fee for the completion of the request only)

Highly secure email (fee for the completion of the request + $20)

Mail (fee for the completion of the request + $20)

GST
Prix: $ 0.00 CAD

QST
Prix: $ 0.00 CAD

Total
$ 0.00 CAD

Please choose a password to receive your file through a secure email*
(You will receive a copy of your documents via a highly secure email. You will need to enter the password you chose in order to access your file.)

Address*
Street Address Address Line 2 City AlbertaColombie-BritanniqueManitobaNouveau-BrunswickTerre-Neuve-et-LabradorTerritoires du Nord-OuestNouvelle-ÉcosseNunavutOntarioÎle du Prince-ÉdouardQuébecSaskatchewanYukon Province Postal Code

Confidential document transmission agreement*
I hereby certify that I am the person identified in this request and I consent to receive my request for this service, as formulated.

Payment

MasterCard
Visa
Cartes bancaires prises en charge : MasterCard, Visa
Card Number Mois010203040506070809101112 Année20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name

Secure payment via PayPal

After clicking on the ''submit'' button, please do not exit this page before being redirected to the confirmation page.

Partial copy of the file

Partial copy of the file

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