Patient Intake Form

Patient Intake
Naturopathic Patient Intake Form

Our professional association requires us to maintain contact information for our patient records. No information will be provided to any other individual or group without your express permission. E-mail will only be used by our office to inform you of our office events and to distribute our newsletter 4-6 times a year; it will not be distributed for any other use.

Instructions for use: Items marked with a " * " are required. You will not be able to submit the form unless ALL required fields have been completed. If you would prefer, you may print a copy of these forms and bring them with you to your appointment. Please do not print this page, you can access a printable version here.

Address
City
Province
Postal Code

Emergency Contact

Please list all medications you have taken, Pharmaceutical, Herbal, Vitamins and Supplements, including dosages.

Please list any allergies you have and the reaction that occurs.

ie: surgery: Jan 1, 2001

How many glasses of water do you drink per day?

How many glasses do you drink per day of the following?

How many cups/day do you drink of the following?

Please complete all that are applicable to you and your family and note who:

Wellness is a balance of many factors. Using the scales below, indicate your level of satisfaction in each area as it relates to you, 10 being the most satisfied.

Context of Care Overview

Welcome to Naturopathic Care

I want you to enjoy and benefit from your visits.

Your first visit will consist of a consultation, detailed history, a general physical exam and more specific naturopathic assessments. Based on this information, initial recommendations for your treatment protocol will be made on your first visit. If it is necessary for a more complete analysis of your health status, you may be asked to have further laboratory tests done, these may include; blood testing, salivary hormone testing, urine, hair and stool analysis. Through this healthcare assessment, a baseline measure of health is established which will be used to monitor your progress.

Naturopathic treatment programs often include dietary changes, botanical/herbal medicine, nutritional supplementation, homeopathy, acupuncture and Bowen therapy. Any side effects or risks associated with your treatment will be explained to you. Part of the program will also involve lifestyle recommendations that are logical and sensible; I encourage you to have a support team as you make these changes, often having someone else, be it a partner, family member or friend, undergoing naturopathic care at the same time, will help ease you both toward better health. Your second visit is a good time to ask any questions that you may have had after your initial visit. If you need immediate clarification on remedies, dietary recommendations or have a concern over any unfamiliar symptoms that may arise, please call the office.

On your following visits your progress will be monitored and treatments will be modified accordingly. The second visit is usually one to four weeks after your initial visit. If you are receiving acupuncture treatments, visits will be more frequent, either once or twice weekly for 6-10 sessions, Bowen therapy sessions are usually 5-10 days apart. As you start to experience a new level of wellness, an office visit every three to four months is recommended for general disease prevention and health maintenance. If an acute, non-emergency condition occurs, please give us a call as we may be able to help with a naturopathic treatment.

Many patients have allergies and are environmentally sensitive. On the day of your visit to the office please do not wear any scented products (perfumes, shaving lotions, etc.).

If you are unable to keep a scheduled appointment, please give the office 24 hours notice. We are then able to give the appointment time to someone else. If we do not receive sufficient notice you will be charged for the missed visit.

Payment for visits shall be made at the time of the appointment

Please be advised of the fees
Dr. Rebecca Sagan ND
Initial visit 1.5 hr $195
Regular visit 30 min $85
Child Initial visit $150
Child Regular visit $79
Acupuncture Initial visit $150
Acupuncture follow-up $89
Bowen Therapy Initial $126
Bowen Follow-up $89

A dispensary of professional quality supplements, botanicals and homeopathics is maintained
for the treatment of our patients. Items are individually priced.

We accept the following methods of payment:
Visa, MasterCard, Debit card, or cash

If you have any concerns please contact the office and we will happily help you to the best of our abilities.

Naturally Good Health Clinic

INFORMED CONSENT

I would like to take this opportunity to welcome you to the Naturally Good Health Clinic. This Clinic utilizes the principles and practices of Naturopathic Medicine and other supportive therapies to assist the body's own ability to heal and to improve the quality of life and health through natural means.

Your practitioner will conduct a thorough case history. Your Naturopathic Doctor will complete a physical exam, as well as, specific blood, salivary and/or urinary laboratory reports as part of the treatment work-up if determined to be appropriate.

Statement of Acknowledgement

As a patient of this clinic I understand that the form of medical care is based on Naturopathic and other supportive principles and practices. All information that is disclosed will remain confidential and will only be released with my permission. I recognize that even the gentlest therapies potentially have their complications in certain physiological conditions or in very young children or those on multiple medications and hence the information provided is complete and inclusive of all health concerns including risk of pregnancy; and all medications, including over the counter drugs and supplements. The slight health risks of some Naturopathic treatments include, but are not limited to; aggravation of pre-existing symptoms, allergic reaction to supplements or herbs; pain, fainting, bruising or injury from venipuncture or acupuncture; muscle strains and sprains, disc injuries from spinal manipulations.

I also confirm that I have the ability to accept or reject this care of my own free will and choice and that I am not an agent of any private, local, county, provincial or federal agency attempting to gather information without so stating. I accept full responsibility for any fees incurred during care and treatment.

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