Our Clinics

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

Monday to Thursday 8:30 am to 4:30 pm
Friday 8:30 am to 12 pm

(613) 702-1000
receptionottawa@thememoryclinic.ca

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

Monday to Friday 9:00 am to 4:00 pm

(514) 400-3903
receptionmontreal@thememoryclinic.ca

Make an appointment

Is the appointment request for you?

Yes, it is for me.
No, I am applying for another person.

    Please complete the form below.

    Gender :

    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.

    Which clinic would you like to be contacted by?

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

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

    For how long, and what are they?

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

    Check all applicable fields :

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

    How did you hear about us?

      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?

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

      Gender :

      Date of birth:

      Address :

      Primary care physician :

      Pharmacy :

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

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

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

      For how long, and what are they?

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

      Check all applicable fields:

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

      How did you hear about us?

      *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.

      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.