1 Your identity
2 Your contact information
3 Your message
4 Summary
5 Fin

File a complaint on the quality of services on my own behalf

Unless otherwise instructed, you have to fill out all the fields.

Your identity

First and last names

Health Insurance Number

Date of birth

Social Insurance Number

Health Insurance Number

Example: Four letters “A”, followed by four nines, followed by four nines

Date of birth

Example: Thirty-one, then slash, then zero one, then slash, then nineteen fifty-five

Social Insurance Number

Example: 999 999 999

Form submission language :Complaint or comment :Souhaitez-vous proposer des pistes de solution au problème soulevé? (facultatif)Contact information :Do not have a Health Insurance Number :I don’t have a health insurance number.Reside outside Québec :Reside outside Québec ext., app.