Contact us

Make an appointment

*Your consultation request will only be sent to members of our team and will be treated confidentially. No information will be sent to your primary care physician or included in your medical record without your prior consent.

While filling out this online request is the best way to reach us, you can also contact one of our clinics during our business hours.

Our mission at Memory Clinic is to participate in medical advances in Alzheimer’s disease. Initial assessments allow us to determine your potential eligibility to participate in one of our research programs. Unfortunately, some people are not eligible to participate.

Here are some examples of conditions that will not allow us to proceed with your application:

– Inability to consent;

– Inability to read and write in English or French;

– Inability to undergo an MRI (metallic implant, pacemaker, severe claustrophobia…);

– Unstable or severe mental health diagnosis.

Is the appointment request for you?

Yes, it is for me.

No, I am applying for another person.

Please complete the form below.

Gender :

FemaleMaleIntersexOther

Date of birth:

Address :

Your primary care physician :

Your pharmacy :

I authorize the Memory Clinic to contact my pharmacy to obtain my current medication list.

YesNo

Which clinic would you like to be contacted by?

OttawaMontreal

Would you be willing to answer a short questionnaire in preparation for our first call?

YesNo

1) Do you or people around you have concerns about your memory?

YesNo

For how long, and what are they?

2) Do your memory difficulties interfere with your daily activities or functioning?

YesNo

Check all applicable fields :

I find it more difficult than before to organize my time, I sometimes forget appointments.I find it harder than before to do my grocery shopping, I forget items, or I buy things I don't need.I find it more difficult than before to find my words, I sometimes forget the name of a loved one or a familiar object.I am having more difficulty paying my bills than I used to.I find it more difficult than before to orient myself in space, even when I am driving.

3) Have you ever received one or more of the following diagnoses :

Mild cognitive impairmentAlzheimer's disease, mild stageAlzheimer's disease, moderate stageAlzheimer's disease, advanced stageEpilepsyParkinson’s DiseaseSleep apneaOther neurocognitive disorders

How did you hear about us?

Social Media (Facebook, Instagram)Family PhysicianWord of mouthConferenceRadioNewspaper/Magazines (paper or online)Online searchOutdoor signageOther:

I consent to the information provided in this form being used to create a record at the Memory Clinic and to be contacted by a member of its staff.

Information of the person completing the application: (we will ask for the patient’s information below)

Which clinic would you like to be contacted by?

OttawaMontreal

Information of the person for whom the application is being completed :

Gender :

FemaleMaleIntersexOther

Date of birth:

Address :

Primary care physician :

Pharmacy :

I authorize the Memory Clinic to contact the pharmacy to obtain the current medication list.

YesNo

Would you be willing to answer a short questionnaire in preparation for our first call?

YesNo

1) Do you or people around you have concerns about their memory?

YesNo

For how long, and what are they?

2) Do these memory difficulties interfere with their daily activities or functioning?

YesNo

Check all applicable fields:

They find it more difficult than before to organize their time and sometimes forgets appointments.They find it more difficult than before to go grocery shopping and sometimes forgets items or buy things they don't need.They find it more difficult than before to find words and sometimes forgets the name of a loved one or a familiar object.They are having more difficulty paying bills than before.They find it more difficult than before to orient themsevles in space, even when driving a car.

3) Has the individual ever received one or more of the following diagnoses :

Mild cognitive impairmentAlzheimer's disease, mild stageAlzheimer's disease, moderate stageAlzheimer's disease, advanced stageEpilepsyParkinson’s DiseaseSleep apneaOther neurocognitive disorders

How did you hear about us?

Social Media (Facebook, Instagram)Family PhysicianWord of mouthConferenceRadioNewspaper/Magazines (paper or online)Online searchOutdoor signageOther:

The person on whose behalf I am completing this form consents to the information provided in this form being used to create a record at the Memory Clinic and to be contacted by a member of its staff.

Ottawa

Ottawa Memory Clinic

Monday to Thursday 8:30 a.m. to 4:30 p.m. – Friday 8:30 a.m. to 12 p.m.

1600 Carling Avenue, Suite 100, Ottawa, ON K1Z 1G3

(613) 702-1000 FAX (613) 702-1001

receptionottawa@thememoryclinic.ca

Montréal

Montréal Memory Clinic

Monday to Friday 9:00 a.m. to 4:00 p.m.

1300, rue Sherbrooke Ouest, 2nd floor, Montréal, QC H3G 1H9

(514) 400-3903 FAX (438) 913-5252

receptionmontreal@thememoryclinic.ca