Pharmacie Familiprix — Questionnaire de consentement

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Scanner code-barres prêt — scannez le dos de la carte RAMQ à tout moment

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Take a clear photo of the front of your RAMQ card to auto-fill your information.

Patient Identification

Please fill in your information

Full Name

Date of Birth

Address

Phone Number

Email Address

RAMQ Number

Expected format: ABCD 1234 5678 (4 letters + 8 digits)