New Patient Intake Form

Please complete the following Intake Form and return to us at least 24 hours prior to your Initial Appointment. 

Any fields that are marked with an asterisk *, are required to be entered before your form can be submitted.

  • Please enter at least one contact phone number
  • Please enter the name of your health fund, if any.
  • Please enter your current height in centimetres, if known
  • Please enter your current weight in kilograms, if known
  • Please enter your blood type, if known
  • Please enter the name of your partner or support person
  • Please enter what your current health concerns are.
  • Please list all Prescription Medications that are currently being taken or type none
  • Please list all Natural Medicines including vitamins that are currently being taken or type none

 

Please note that payment is due on the day of treatment.  We request at least 24 hours notice to change or cancel appointments.  A $50.00 administration fee will be charged for late cancellations/changes or non attendance of appointments.