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Child Intake Form

Please take a moment to fill out our online intake form before your visit. All information is kept completely confidential.

Multi-line address
Date of birth
Day
Month
Year
Select all known ALLERGIES.
FAMILY HISTORY (Mom/Dad/Siblings/Grandparents)
Which of the following diseases has your child had?
Which of the following immunizations has your child had?
Has your child had any screening test (i.e. blood, hearing, vision)?
Yes
No
Other
Did your child ever experienced colic?
Yes
No

Mother:

Father:

Did the mother experience any of the following during the pregnancy. Check all that applies.
Did the child experience any of the following at or shortly after the birth?
Does anyone in the child's household smoke?
Yes
No

NATUROPATHIC MEDICINE INFORMED CONSENT

Naturopathic medicine is the treatment and prevention of diseases by natural means. Naturopathic doctors assess the whole person, taking into consideration physical, mental, emotional and spiritual aspects of the individual. My ND will take a thorough case history and perform a relevant physical examination. It is very important that I inform my naturopathic doctor of any medical concerns or medication and supplements I may be taking. I will advise my ND if I am pregnant, suspect I am pregnant or if I am breastfeeding.


As a patient I will receive information about my diagnosis and/or treatment, alternative courses of action, the material effects, costs, expected benefits, risks, side effects and in each case the consequences of not having the diagnosis and/or treatment acted upon. As with any form of medical intervention there can be health risks associated with treatment by naturopathic medicine. Possible side effects of naturopathic medical care include:


  • Aggravation of pre-existing symptoms

  • Allergic reactions to supplements or herbs


I understand that my naturopathic doctor cannot prescribe over text, whatsapp or email without having a consultation to go over pertinent information such as my signs, symptoms and lab results to fully understand my situation to prescribe a customized treatment plan just for me.


I understand that the results are not guaranteed. I do not expect the naturopathic doctors to be able to anticipate and explain all risks and complications. With this knowledge, I voluntarily consent to Naturopathic care I intend this consent form to cover the entire course of treatment. I understand that I am free to withdraw my consent at any time.

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