CMIE Registration Request Form - CMIE - Clinique privée

Skip to content

Information and consultation: 450-332-2430

Search for:

Home
Medical Services
Specialized Services
Health Network
About CMIE
Client area
- Online appointment booking
- Patient portal
Contact

Home
Medical Services
Specialized Services
Health Network
About CMIE
Client area
- Online appointment booking
- Patient portal
Contact

CMIE Registration Request Form

This form allow you to register to CMIE and a member of our team will contact you to open your patient file subject to applicable file registration fees.

Hidden

Next Steps: Install the User Registration Add-On

Ce formulaire d’inscription permet à l’équipe du CMIE de vous contacter afin d’ouvrir votre dossier patient. Les formulaires d’adhésion et de consentements vous seront acheminer via le Portail Patient sécurisé et confidentiel du CMIE.

Name(Required)

First name Last name

Date of birth(Required)

YYYY dash MM dash DD

Gender(Required)

Male

Female

Non-binary

Agender

My gender is not listed

Prefer not to answer

Email address(Required)

Enter your email address Confirm your email address

Phone number(Required)

Postal address(Required)

Street number and name Address Line 2 (if needed) City Province Postal code

Name, address and phone number of your pharmacy(Required)

Requested service(s)(Required)

Check all applicables services you would like to obtain at CMIE.

Family medecine

ADHD screening

Medical cannabis / Pain management

Vaccination and sampling

Life coaching

Health coaching

Nutrition and naturopathy

Audioprosthetists

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

© 2024 CMIE - Privacy Policy

Scroll to Top