Registration Form

Name of person completing this form: (required)

Date: (required) (YYYY-MM-DD)

Client's Information

Client's last name: (required)

Client's first name: (required)

Age:

Date of birth: (YYYY-MM-DD)

Gender Identity:
Male/ManFemale/WomanTransMale/TransManTransFemale/TransWomanGender Neutral/Gender NonconformingSomething elseDecline to answer

Marital status:
MarriedSingleSeparatedDivorcedN/A

Person with limited mobility:
YesNo

Address:

If client is under legal guardianship, please provide the name and role of the legal guardian:

Client’s home phone number:

Client’s cell phone number:

Client’s work phone number:

Client's email:

Please note that we may contact you by email:
YesNo

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Parent or caregiver's name:

Parent or caregiver's telephone number:

Parent or caregiver's email:

Parent or caregiver's relationship to client:
MotherFatherCaregiverOther

Parent or caregiver lives at the same address?
YesNo

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2nd Parent or caregiver's name:

2nd Parent or caregiver's telephone number:

2nd Parent or caregiver's email:

2nd Parent or caregiver's relationship to client:
MotherFatherCaregiverOther

2nd Parent or caregiver lives at the same address?
YesNo

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Client’s RAMQ number:

Expiration date: (YYYY-MM-DD)

Name on the card:

How did you hear about Clinique Spectrum?
Family / FriendsSocial MediaDoctorOther

Type of service requested

What type of services are you looking for?
Diagnostic assessment

Scheduling of appointments

Who should we contact regarding the scheduling of appointments?
ParentCaregiverOther

Name:

Telephone:

Email:

Parent's RAMQ information

Parent’s RAMQ number if accompanying the client:

Expiration date: (YYYY-MM-DD)

Name on the card:

Person responsible for billing

Name:

Relationship to client:

Email:

Home telephone number:

Date of birth: (YYYY-MM-DD)

Address if different from client:

Pharmacy

Name of pharmacy:

Telephone:

Address:

Fax number:

In case of an Emergency

Name of local friend or relative (not living at the same address):

Relationship to client:

Home telephone number:

Cellular:

By clicking send I confirm the above information is true to the best of my knowledge. I acknowledge that I have requested services from Clinique Spectrum from my free will and was not solicited by Clinique Spectrum or its associates. I also acknowledge that my clinical information will be entered onto OSCAR, Clinique Spectrum’s secure EMR (Electronic Medical Record) and that my nominal information will be visible to the healthcare professionals working at Clinique Spectrum. The data stored about me is encrypted.

Prior to filling out our forms, please ensure that you have the consent of the individual for whom you are filling out the forms (in the case of a minor, or an adult with an incapacity). Please read our privacy policy to learn more about how your personal information is protected through our website and communications.

Please also read below for our cancellation policy and services that are not covered by the RAMQ.