Privacy Policy

Privacy of your personal information is important to your Naturopathic Doctor (ND). In providing you with quality naturopathic care, your ND is committed to collecting, using and disclosing your personal information responsibly. Your ND will strive to be as transparent as possible about the way she handles your personal information. To help you understand how she is protecting your information, she will outline how the clinic is using and disclosing your information.

Your ND will collect, use and disclose information about you for the following purposes:

To assess your health concerns
To provide health care
To advise you of treatment options
To establish and maintain contact with you
To send you newsletters and other information mailings
To remind you of upcoming appointments
To communicate with other health-care providers
To allow for efficient follow-up for treatment, care and billing
To complete claims for insurance purposes
To invoice for goods and services

To process credit card payments
To collect unpaid accounts
To comply with all regulatory and legal requirements including court orders, statutory requirements to advise authorities of child abuse and reporting diseases and individuals who may be an imminent threat to harm themselves or others
To use for educational and research purposes (this includes case summaries, photographs, lab results and other pertinent medical information). Your identity will be protected at all times and if necessary, identifying information will be altered to protect your privacy in all the above instances

By typing your name in the designated section of the Naturopathic New Patient Paperwork, you will agree that you have given your consent to the collection, use and/or disclosure of your personal information as outlined above.

Informed Consent

Please note that this form must be signed prior to your first appointment.

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. Gentle, non-invasive techniques are generally used in order to stimulate the body’s inherent healing capacity. Your Naturopathic Doctor (ND) will take a thorough case history, perform a physical examination and may order blood and urine testing. If your case requires, the physical may include more specific examinations such as gynecological, breast, rectal, prostate or genital exams.

It is very important that you inform your Naturopathic Doctor immediately of any disease process from which you are suffering and any medications/over-the-counter drugs that you are currently taking. Please advise your ND immediately if you are pregnant, suspect you are pregnant or if you are breast-feeding.

As a patient you will receive information about your diagnosis and/or treatment, alternative courses of action, costs, expected benefits, risks, side-effects and in each case the consequences of not having the diagnosis and/or treatment acted upon.

There are potential health risks associated with treatment by naturopathic medicine. These include but are not limited to:

Homeopathic remedies may occasionally result in the aggravation of pre-existing symptoms. When this occurs the duration is typically short, will often self-resolve, or can be managed by notifying your practitioner.
Some patients may experience allergic reactions to supplements and herbs. Please advise your ND of any allergies you may have.
Pain, bruising or injury from acupuncture; fainting or puncturing of an organ with acupuncture needles.

Your Naturopathic Doctor is trained to handle emergencies should the need arise.

By typing your name in designated section of the Naturopathic New Patient form, you understand that:

Your Naturopathic Doctor does not guarantee treatment results.
Your Naturopathic Doctor will explain to you the exact nature of any treatment provided and will answer any questions you may have.
You are fee to withdraw your consent and discontinue treatment at any time.

Find the Naturopathic New Patient Paperwork here!

Naturopathic Patient Paperwork

Step 1 of 7

Privacy Policy and Informed Consent*
By typing your name in the field below, you acknowledge that you have read and agree to the policies listed above.
This is a confidential health assessment tool which will give insight into your personal health status. When designing an individualized health plan it is important to begin with a thorough understanding of where you are currently, your personal and family history, as well as your health, habits, concerns and thoughts with respect to your health. Please take the time to answer the questions on this form as honestly and accurately as possible.*
- I agree to answer this form as honestly and accurately as possible.

Patient Information
Name*
First Last
Birth Date*
Gender*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone*
Secondary Phone
Email*
Best way to reach you*
Status*
Do you have children?*
- Yes
- No
How many children do you have?*
What are the ages of your children?*
What is your occupation?*

Emergency Contact Information
Name*
First Last
Relationship*
Phone Number*
Current Health Concerns
Please list your current health concerns in order of importance to you.*

Medical History
Please list current/past illnesses and hospitalizations including dates.*
Allergies/sensitivities (environmental, foods, pets, drugs, etc.)*
Are you currently pregnant?*
- Yes
- No
Have you received all childhood vaccinations?*
- Yes
- No
Any complications from vaccinations?*
Date of your last Annual Physical Exam/Blood Test:*
If unknown please select 01/01/2001.
Date of last Antibiotic Use:*
If unknown please select 01/01/2001.
Please list all medications and supplements that you take including brands and dosages.*
Family Physician
Name
First Last
Phone
Fax
Address/clinic location

Family Medical History
Please indicate all past and current medical conditions and/or hospitalizations both Paternal and Maternal.
Father
Paternal grandfather
Paternal grandmother
Mother
Maternal grandfather
Maternal grandmother
Siblings

Naturopathic Care New Patient Paperwork

Privacy Policy

Your ND will collect, use and disclose information about you for the following purposes:

Informed Consent

Find the Naturopathic New Patient Paperwork here!

Naturopathic Patient Paperwork

Step 1 of 7

Patient Information

Emergency Contact Information

Current Health Concerns

Medical History

Family Physician

Family Medical History

Diet and Lifestyle

Please describe what you typically eat in one day:

This is the end of the form. We will be in touch with you shortly!

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