Registration for access to a family doctor Centre de santé et de

Registration for access to a family doctor
(Guichet d’Accès pour clientele sans médecin de famille)
Centre de santé et de services sociaux des Collines
* Please fill in in BLOCK LETTERS
* Persons aged 14 or older must complete this form by themselves; one for mis required for each person.
Client Identification
Health Insurance No. :
Name :
Given Name :
Address :
City :
Postal Code :
Telephone No. (Home):
(Work) :
(Other) :
Location of CLSC :
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
_________________________
_____________________ ___
___________________ Extension ________
_________________________
 Cantley
 Chelsea
 Masham
 Val-des-Monts
Date of registration :
Date of birth
: ____________________
(YYYY-MM-DD)
Age :
____________________
Gender :  female  Male
Preferred Language :
 French
 English
 Other : ____________________
Referral
Origin of referral :  User
 Network Professional
 Medical Clinic
 CSSS (specify) ____________________________
 Other (specify)___________________________
Last Family Doctor : _________________________________________
Last visit : __________________
Details (as required) :
_______________________________________________________________________________
_______________________________________________________________________________
Evaluation
Do you have any diagnosed illnesses ? Specify :___________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
How is your state of health ? :
 Chronic
 Under Treatment  Uncontrolled
 In Remission  Controlled or Stable  Other (specify) : _______________________
Do you take medications ? If so, specify : _______________________________________________________________
_______________________________________________________________________________________________________
Are you currently receiving care from a CLSC? specify : __________________________________________________________
_______________________________________________________________________________________________________
Are you being treated by a specialist ? If so, which one ?
___________________________________________________
Have you been hospitalized in the last two years ? If so, place and reason : __________________________________________
_______________________________________________________________________________________________________
Have you had surgery in the last 2 years ? If so, place and reason : _________________________________________________
_______________________________________________________________________________________________________
Did you visit an emergency room in the last year ? If so how many times ?___________________________________________
Do you have any health conditions and/or handicaps that limit your mobility ? If so, specify :
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Other comments : ________________________________________________________________________________________
_______________________________________________________________________________________________________
I hereby authorize the Guichet d’accès pour clientele sans médecin de famille to retain the information herein in a secure central bank, with the
understanding that my application be kept in compliance with all confidentiality rules. I also authorize the CSSS des Collines to transmit such
information for the purposes of providing the care of services required by my health condition to the physician who will agree to become my
family doctor. This consent is valid for the duration of this request for services.
Signature :
If sent by mail :
X___________________________________________________
(Signature required if not transmitted online)
Date : ____________________________________
Guichet d’accès pour clientèle sans médecin de famille
Centre de santé et de services sociaux des Collines
490 Route 105, suite 201
Chelsea (Québec) J0X 3G0
Guichet d’Accès pour clientèle sans médecin de famille au 819 459-1112 poste 2521
M:\Ressources humaines\Roxane\CLSC\Guichet_MedecinFamille_GACO\Formulaire_GACO_Anglais.docx