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Appointment Request - Valérie Kula, Orthophoniste
5010 Rue Wellington, bureau 200.2, Montréal, Quebec, H4G1X9, Canada
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Thanks for requesting an appointment with our practice.
The information has been received and we will get back to you shortly.
Complete a new form
Click here
to download the completed form by accessing the client portal
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First Name
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Last Name
*
Contact information
Phone number
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Email
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Child's Name:
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Child's Birth Date
*
Name of Parent/Guardian:
*
Relationship:
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Appointment request
Thank you for your interest in our practice!
What day(s) of the week is it easier for you to come for an appointment?
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Please answer this question.
Monday
Tuesday
Wednesday
Thursday
What time of the day is usually better for you?
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Please answer this question.
Morning
Lunch time
Afternoon
What is the reason of your visit?
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Is there anything else you would like to specify? (optional)
Has your child been seen in audiology, neuropsychology or speech-language pathology? If so, please send the report(s) to valerieorthophonie@gmail.com
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No
Yes
No
Details
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Which services are you interested in?
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Please answer this question.
Assessment
Intervention
Parental Coaching (3 years and under)
How did you hear about us?
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