Pharmacist Consultation Please enable JavaScript in your browser to complete this form.Name *FirstLastDate Of Birth (DD/MM/YYYY) *Address *Street, City, Postal CodePhone Number *Email *Reason For Visit *Family Doc's InfoFirst Name, Last NameGDPR Agreement *I consent to having this website store my submitted information so they can respond to my inquiry.Consents *Upon submitting this form online I am electronically signing above formOur office often uses email to communicate with patients. This information may be confidential and personal in nature. Although we are very careful on our end to keep these emails confidential, you should know that email messages in general are not encrypted and may exist indefinitely. We cannot guarantee the security of messages sent outside of the clinic. The clinic cannot guarantee that your email will be received, read or responded to within any particular period of time. YOU MUST NOT COMMUNICATE WITH THE CLINIC VIA EMAIL FOR MEDICAL EMERGENCIES or other time-sensitive matters. I agree that email may be used to send personal health information to me Please do not use email for urgent clinical mattersSubmit
