Register for an initial consultation Please fill out this form to complete your registration.One of our team members will contact you to give you an appointment as soon as possible.info@cliniqueiuvo.ca(514) 242-70127655 Newman BoulevardSuite 185LaSalle, QC H8N 1X7 Client's Name * Prénom Nom de famille Date of Birth * MM JJ AAAA Email * Phone * (###) ### #### Parent's Name (if client is a child) Prénom Nom de famille Service Wanted * Speech-Language Pathology Preferred Language for Services * English Français Name of School (if child is of school age) Message * Please indicate the services you are inquiring about, as well as difficulties you/your child are experiencing relating to speech-language pathology How did you hear about us? * Facebook Page Health Professional Friend or Family Our website Ordre des orthophonistes et audiologistes du Québec Other Ordre des psychologues du Québec Consent to Personal Data Collection * I confirm that I have read 'Clinique IUVO's Confidentiality Policy' Yes, I have read and I accept the Confidentiality Policy Thank you for filling out our form! You have been added to our waitlist. The personal information provided in this form is confidential and is solely used as a means of contacting you to offer you services at our clinic. Once you are a client, this information will be kept by the professional in your file, as well as in our appointment/accounting software. This information is protected and only accessible by the staff at Clinique IUVO.A professional from our clinic will be in contact with you to schedule an initial teleconsultation. This session serves to open up your file with the clinic, discuss your situation as well as establish the steps needed to proceed (ex. evaluation, costs, follow-up). For neuropsychology, a professional from our clinic will be in contact with you to schedule an appointment and discuss the cost of evaluation.If you wish to be taken off the waitlist, please e-mail us at info@cliniqueiuvo.ca.Have a nice day!
