Naturopath Intake History Form

Your name

Birth Date (dd-mm-yyyy)

Date

Height

Weight

Age

Occupation

Address

City

Postal Code

Home Phone

Work Phone

Mobile

Who can we thank for referring you to us?

Other family members under our care:

Other Health Care Provider(s):

Name

Work Phone

Name

Work Phone

Context of Care Overview:

What are your health concerns, in order of importance to you?

List any other concerns you would like to discuss:

Do you get regular screening tests done by another doctor? (Pap, blood tests, etc.)

If yes, please specify

Primary Insurance Company

Patients Full Name:

Insurance Company:

Insurance Policy Number:

File Number:

Name of Plan Member:

Policy Start Date:

Secondary Insurance Company

Patients Full Name:

Insurance Company:

Insurance Policy Number:

File Number:

Name of Plan Member:

Policy Start Date:

INFORMED CONSENT TO TREATMENT & EMAIL COMMUNICATION

I understand that the Pickering Wellness Centre's clinic naturopath is a Naturopathic Physician, and will use only natural, non-invasive methods of assessment and treatment.
I understand that any advice given to me as a patient at Pickering Wellness Centre is not mutually exclusive from any treatment or advice I may now, or in the future, be receiving from another health care provider.
I understand that I am at liberty to seek, or to continue medical care from another health care provider qualified to practice in Ontario.
I understand that the Naturopathic Doctor reserves the right to determine which cases fall outside of their scope of practice, and an appropriate referral will be recommended.
I understand that I am accepting or rejecting this care by my own free will.
I understand that no employee or Naturopathic Doctor at Pickering Wellness Centre is suggesting to me to refrain from seeking the advice of another health care provider.
I understand that the services offered here are not covered by OHIP, and that fees are payable at the time of appointment; including fees for services, prescriptions, and laboratory tests.
I understand that 24 hours' notice is required for appointment cancellation, otherwise I will be responsible for the cancellation fee.
I understand that any therapies recommended will be explained to me in full by the Naturopathic doctor, and that I will give consent to treatment based on informed consent.
I agree to disclose any and all medical conditions which may affect the effectiveness or side effects of Naturopathic care
I consent to receive and to transmit information via email with Pickering Wellness Centre.
I place no liability upon Pickering Wellness Centre's Naturopathic Physician or the Pickering Wellness Centre for unforeseen effects or side effects of the treatments received.

Consent to Treatment:

Name: ...................................................................

Date: ...................................................................

Signature: ...................................................................