• These forms are for patients that have made appointments. If you have not made an appointment please call us at 905-684-4934. To fill out the New Patient Form please use a computer. Mozilla Firefox, Ipads and Mobile devices will not work.

  •  - -
    Pick a Date
  •  - -
    Pick a Date
  • ***APPOINTMENTS***48 hours notice is also required for ALL cancellations of appointments. A $40 fee will be charged for a missed appointment, if no prior notice is given to our office. Should you fail to attend your initial appointment with us without notice you will be billed up to 50% of the initial visit fee. By notifying us of your change in schedule, you allow someone else to receive the vital treatment they need. Please take a few minutes to answer the questions in ink on the following pages. All of your medical information is of value to us. If your condition is not well covered by the questions that follow, please feel free to write it in. Please read the enclosed fee schedule.I have read the fee schedule and asked questions to clarify anything that was not clear to me. I completely understand what I am signing and agree to abide by the clinic rules as outlined above. 
     
  • (If under 16 years of age, a parent or guardian must agree.)
  • I HEREBY CONSENT TO TREATMENT AT NATURE MEDICINE INC. AND FOR MY FILE TO BE REVIEWED BY ANY OF THE MEDICAL STAFF AS IS DEEMED NECESSARY FOR MY BEST HEALTH INTERESTS. 
     
  • Please note: The more detailed information you provide the more efficient and effective we can be when treating you.
  • Chief concern additions
  • Do you have any medical alerts? i.e. diabetes, allergies to medication
  • Energy:
  • Sleep:
  • Exercise:
  • Please check off those conditions which were a problem for you in the past or presently causing you problems.












  • Bowel Movements:
  • Women menstrual history:
  • Pregnancies:
  • Menopause history:




  • Family History  (eg. Diabetes, heart disease, stroke, asthma, allergies, epilepsy, cancer, high blood pressure, mental disorders, alcoholism) 
  • Medication / Supplement
  • Diagnostic testing: Please list any recent tests you have had and what was found (eg. X-rays, ultrasounds, MRI’s, CT’s, blood work, biopsies)
  •  


  •  

  •  
  • ENVIRONMENTAL Please check those factors that apply to you
  •  

  • Please run the wizard
  • Thank you for answering all the questions. Complete answers to all of the questions are to your benefit for the most effective naturopathic treatment. This is a confidential record of your medical history and will be kept in this office. Information contained here will not be released to any person except when you have authorized us to do so. 
  • © 2001 NaturoMedic™.com
  • Should be Empty: