Registration form
Point of access for clientele
without a family physician
IDENTIFICATION OF THE USER
If the information on the hospital card is correct, make its impression here.
If not, complete the identification of the user.
RAMQ #: ______________________________________________ Date of birth: ____________________________________________________
Family name/Given name: ______________________________________________________________________ Sex:  Male
 Female
Address:________________________________________________ Telephone (home): ______________________________________________
Do you have voicemail:  Yes
 No
City/Town: _____________________________________________ Telephone (work): _______________________________________________
Postal code: _____________________________________________ Telephone (other): _______________________________________________
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Yes
No
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Do you have any diagnosed illnesses? If yes, please list them: ____________________________________________________
_________________________________________________________________________________________________________
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Do you take any medications? If yes, approximately how many? __________________________________________________
List your medications here or attach a list: _______________________________________________________________________
_________________________________________________________________________________________________________
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Are you currently receiving services from the CSSS? (e.g. diabetes centre, psychosocial screening, outpatient clinic, etc.)
If yes, which? _____________________________________________________________________________________________
_________________________________________________________________________________________________________
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In the past two (2) years, have you been hospitalized?
If yes, in which institution? ___________________________________________________________________________________
For what? ________________________________________________________________________________________________
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In the past two (2) years, have you undergone surgery?
If yes, in which institution? ___________________________________________________________________________________
For what? ________________________________________________________________________________________________
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In the past year, have you seen a doctor at Emergency?
If yes, approximately how many times? ____________ For what? __________________________________________________
_________________________________________________________________________________________________________
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If you are a woman, are you pregnant?
If yes, what is your expected due date? ________________________________________________________________________
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Are you in the care of a specialist? If yes, which specialist? _______________________________________________________
For what? ________________________________________________________________________________________________
Which is your regular pharmacy? __________________________________________________________________________________________
Who was your last family doctor? __________________________________________________________________________________________
Your reason for changing doctors: __________________________________________________________________________________________
By submitting this form, I hereby consent that the information collected for my registration be kept in a secure database ans transmitted to the doctor
who is witting to provide my medical care.
Form completed by:  User  Other : ____________________________________________________________________
MAJ: 2014-10
What is the Registry?
Clients with no family doctor may enrol in the Registry for Clients in Search of a Family Doctor.
The information contained in this database will help better connect the needs of the clientele with the
available medical services in the region.
Please note that it is not a waiting list. It is therefore useless to call us to find out where you are on the list.
This registry does not guarantee the allocation of a family doctor for you, but it will allow us to:
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Identify all the clientele in the territory who are without a family doctor;
Evaluate the clientele in order to determine their degree of vulnerability;
Facilitate the case management of clients by local doctors or by new doctors who may in future set up
their practices here, according to the clients’ degrees of vulnerability;
Guide us in the creation of temporary pilot projects in order to make up for the lack of local doctors.
In order to qualify for the Registry for Clients in Search of a Family Doctor at the CSSS des
Sommets, you must:
• Live in the territory of the MRC des Laurentides. If you live in another MRC, please register in the
CSSS that serves your area.
•
Complete the annexed form and use one of the following methods to send it to us:
 Bring it to the reception at one of our CLSCs, either in Ste-Agathe, Mont-Tremblant or Labelle.
 Fax it to 819-324-4108
 Mail it to the following address:
CSSS des Sommets
Édifice Grignon
Registry for clients in search of a family doctor
234, rue Saint-Vincent
Ste-Agathe-des-Monts, (Québec)
J8C 2B8
 This form is also available in its electronic version at www.csss-sommets.com
You can fill in the form online then print it and send it in by one of the methods described above.
Every registration is important
After completing and returning this form, you will be contacted to confirm your registration and to draw up a
complete picture of your situation and your needs for health services.
Processing may be delayed by up to several weeks due to the fluctuation in the volume of requests
received.
For all urgent health problems, contact 8-1-1 or
come to the Emergency Department closest to
your home.
Source: CSSS Antoine-Labelle
DSPSH Septembre 2013