Home Care in the Gatineau area

Getting care

By completing this short form, we will be able to contact you to offer you quality care tailored to your needs. You can also call us at 819 595-0790.
and we will be happy to assist you.

Patient's first name

Patient's last name

Patient's date of birth (yyyy/mm/dd)

Applicant's first and last name (if different from patient's)

Applicant's e-mail address

Applicant's phone number

Relationship between applicant and patient (if applicable)

Type of care

Treatment address

City

Postal code

Comments

I agree that the information provided in this form may be shared with our partner, Bien Chez Soi Outaouais, solely for the purpose of processing my request for home care and support services.

I accept and understand that my information will be used in accordance with the company's privacy policy.