Please make sure that your attachment is clear and legible. We do not process incomplete applications or provide appointments without a copy of the referral. If you do not attach your referral, you will need to fax it to the department directly. Wait times depend on the priority assigned to the referral and can be as long as several months.

Patient Information

Child's last name*

Child's first name*

Date of birth*

Year

Month

Day

MCH Medical record number (if known)

Health insurance card number*

Health insurance card expiration date*

Year

Month

Day

'DD' corresponds to the child's date of birth.

Address*

Select your province or territory*

City*

Postal code*

Contact Information (for parent or guardian)

Your first name*

Your last name*

Your relationship to patient*

Email address

Phone number*

Alternate phone number

Comments

CAPTCHA

Language and cultural interpretation services are available in the various clinics and units, in the emergency department, and by telephone. Interpreters are available 24 hours a day to help staff communicate effectively with patients and families in over 300 languages and dialects.

To request this service, all you have to do is let the care team know that you need an interpreter.

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514 412-4400

1001 Boulevard Décarie Montréal, QC H4A 3J1

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