Intake Form

Patient Information

Contact Information

Emergency Contact Information

Other Healthcare Providers

Clinic Information

Health Concerns

Ambitions

Medication and Supplements

Please list any prescription medications, over the counter medications, vitamins or other supplements you are taking with dosages and frequency. If you do not take any medications or supplements, please write 'none' in the first blank.
Do you use or have any of the following?

Allergies & Sensitivities

Context of Care Review

What 3 expectations do you have from your first visit?

General Information

Please rate the following on a satisfaction scale of 0-10, 10 being the most satisfied:
1. I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. 2. I understand that my personal and medical information is confidential and will not be disclosed to third parties without my written permission. 3. On a case-by-case basis, with written consent, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as necessary for my beneficial treatment.1.
I understand my appointment time is reserved just for me. A late cancellation or missed visit leaves a schedule gap that could have been filled by another patient. As such, I agree to provide at least 24 hours notice for any cancellations or changes to my appointment. If I provide less than 24 hours notice, or miss my appointment ('no-show'), I will be charged for the full cost of the missed appointment.
Initial - $190, Regular Follow Up (15-30 mins) - $95, Extended Follow Up (30-45 mins) - $142.50 Additional treatments and testing are variable in cost and will be discussed with you.