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Women's Health Consultation Request
Our experts are here to help improve your health! To request a consultation, please submit the form below:
(Note: The fee for a one hour consultation is $200 tax included)
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First Name
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Your answer
Last Name
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Your answer
Email
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Your answer
Address
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Your answer
Phone Number
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Your answer
Date of Birth (DD/MM/YYYY)
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Your answer
Health Card Number
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Your answer
Primary Physician's Name
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Your answer
Would you like an in-person or virtual consultation? (In-person appointments take place in-store only. We have a private consultation room at Brant Arts IDA Pharmacy located at 672 Brant St. Burlington)
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In-Person
Virtual (phone call)
If you have a Brant Arts Practitioner of choice, please notify us at this time. (We will do our best to accommodate based on availability)
Kerry Roberts (Pharmacist, Women's Health Expert, Certified Menopause Practitioner)
Carolyn Whiskin (Pharmacist, Women's Health Expert, Certified Menopause Practitioner)
No preference
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We're so glad you're here and look forward to connecting with you. Please tell us, how did you hear about our Women's Health Program?
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Friend or family member
Doctor or healthcare professional
Brant Arts staff member
In-store advertising (poster, handout)
TV/News
Podcast or Radio
Facebook
Instagram
Other:
We’d love to be a key part of your wellness journey! We occasionally send uplifting emails with valuable tips focused on your health. Would you like to join us & receive this information?
Yes, keep me inspired with fantastic health tips and updates!
Any notes/messages for us at this time?
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