Registration form for the Metabolic Health Clinic

Personal informations

Name(Required)

First name Last name

Date of birth(Required)

E-mail(Required)

Enter your email address Confirm your email address

Primary phone(Required)

Adresse postale(Required)

Street number and name Address line 2 (If required) City Province Postal code

Name and address of your pharmacy(Required)

How did you hear about us?

TV show, books

Social media

By my relatives/ friends/ family

By my doctor or health professional

Other

Metabolic Health Clinic Pricing
The first appointment is usually about 60 minutes, or $450, but it could be a little less or a little more, depending on your needs. The final cost will depend on the total duration. If follow-up is necessary (a decision taken jointly by you and the doctor), you must pay the CMIE CA. Follow-ups are, in general, 30 minutes. These costs are not reimbursed by the RAMQ.

In order to better meet your needs and optimize the metabolic health consultation, please answer the following questions to the best of your knowledge.

For what reason(s) do you want to consult?(Required)

Name the referring health professional

What is your main goal?(Required)

What is your sleep quality and duration? Explain how you feel when you get up in the morning.(Required)

Describe your eating habits: how often do you eat a day? Describe your typical lunches, dinners and dinners. Do you drink drinks that contain sugar (liquor, juice, coffee with sugar, etc)?(Required)

How much alcohol do you consume each week?(Required)

What physical activity do you do?(Required)

What is your method to manage your stress?(Required)

What is your family and personal history worth mentioning?(Required)

Who is your family doctor?

Would you like to have blood drawn before our meeting (there must be at least 2 weeks between the blood test and the medical consultation)? If yes, please tick:

Complete thyroid (will have to be done privately, such as Lilium, Biron, CDL or Dynacare)

Complete metabolic (includes thyroid basal and metabolic markers)

Female sex hormones (perimenopause or menopause)

Male sex hormones (suspected testosterone deficiency or andropause)

I don’t know, I’ll let you decide

Other…

Additional Specifications or Comments:

Champ de certification(Required)

Rates: Initial consultations with Dr. Bourdua-Roy usually last 60 minutes and will cost $450 for one hour. Follow-ups can be from 20 to 60 minutes and billing will be based on the number of minutes used. I confirm that I have read the rates.

Champ de certification(Required)

By checking this box, I confirm that I have understood that I must have my blood tests done at least 2 weeks before the meeting with the doctor. I understand that otherwise, the meeting will have to be postponed or I will have to accept that the results of my blood tests cannot be discussed at the first appointment.

CAPTCHA

Personal informations

What customers say

Subscribe to the CMIE newsletters