New Patient Inquiry

Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Phone *

(###)

###

####

Preferred method of contact *

Phone

Email

Preferred Date *

Please note current business hours are Monday, Tuesday, and Wednesday from 9am-1:00pm

MM

DD

YYYY

Have you worked with a naturopath or complementary health practitioner before?

Yes

No

How committed are you to making dietary and lifestyle changes if recommended? *

Very committed

Somewhat committed

Not sure

Preferred appointment style *

Please note it is my preference to have at least the initial appointment in person as it may be necessary to do a physical examination.

In person

Online

Either

I understand that this enquiry does not guarantee an appointment, and that some cases may be referred to another healthcare provider if more appropriate. *

Please note that a more detailed intake form will be required to be completed upon securing a booking.