- CSSS - Centre de santé et de services sociaux de Papineau

The online form will be available shortly.

You must enter all the information below. When you have completed the form press send button.

First name :

Family Name :

Health Insurance number :

Date of birth :

Phone number (home) :

Other phone :

Address :

Who was your last family doctor?

Who prescibes your medications ?

When do your prescriptions expire ?

Are you treated by a specialist ?

Email :

I agree to have a summary of my record transferred to the physican who will take me in charge. Yes No

Health issues (diabete, surgery, etc.) :

List of your medications :

As we cannot guarantee that you will be taken in charge rapidly, we suggest that you go to a walk‐in clinic, or to the emergency if necessary.

We enable you to download a PDF version, then print it, complete it and send it by mail or by fax. Click on the link below to get printable version.