Patient Referral

Use this online form or its PDF format to share relevant information with us so that we can contact the patient promptly.

Download the form in PDF

1. Patient informations

Last name *

First name *

Date of birth *

Main phone number *

Contact person (if other than the patient)

Full name of contact person

Contact phone number

Does the patient have insurance?

RAMQ

Private

RAMQ

Insurance information

Name of specialty medication

2. Documents to attach

Please attach a copy of the prescription (mandatory), the pharmacological profile, or any other relevant information

Upload or drag and drop a file

This field is invalid

3. Pharmacist information

Full name of pharmacist

Pharmacy phone number

Other comments

How did you hear about us ?

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Select an answer
Convention/Kiosk
Advertising
Social Media
Conference
Colleague
Other

The different choices were explained and understood by the patient. Among these choices, the patient opted for Larivière et Massicotte Pharmaciennes Inc.

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