New customer form

Your personal information

About your consultations:

Where would you want to meet with us?
—Please choose an option—RemoteSpécifik Performance (2260, rue des Carrières, Montréal)Clinique Sport Santé Laurentides (26, avenue Lafleur sud, Saint-Sauveur)Mouvement Optimal (384, rue de St-Jovite, Mont-Tremblant)Évolution Physio (3115, Boulevard de la Pinière, suite 110, Terrebonne)Clinique Chiroaxion (2174 boul. Marie-Victorin, Longueuil)Centre Totem (544A Rue Notre-Dame, Repentigny)Clinique l'Avenir (1575, Boulevard de l’Avenir, bureau 440, Laval)

If you are a minor:

Your Objectives:

What are the food habits that you would like to work on over the next three months?

What are your perfomance or wellness goals?

Au niveau individuel, quels sont les sujets que vous aimeriez approfondir:
SupplementsWeight managementRecipesRecoverySnacksTripsRestaurantsDetailed meal plansEating and competing

We'd love to have your comments and questions and would be happy to answer them

Please validate the following statements
I understand that a cancellation fee corresponding to 50% of the price of the scheduled consultation will be billed to me if I notify less than one working day before my appointment for a cancellation
I am informed and I accept the prices and methods of payment. We prefer payments by interac transfermade immediately after receiving the service.
By checking this box, I confirm that: I have not been diagnosed with COVID-19 in the last week. And that if I have symptoms that may be contagious, I agree to wear a mask out of respect for the professional and the other clients of the clinic.
I give my consent to use the Zoom platform for remote consultations, if this is the case.
I agree to receive information via email.

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