Adult Intake Dr. Megan Bernard

Please complete this form and return before your first visit

Naturopathic Doctor Intake Form

* Indicates required field

Name *

First

Last

Age *

Date of birth *

Gender *

Email *

I would like to receive the clinic's monthly newsletters & occasional wellness tips *

Yes

Phone Number *

Occupation *

May we leave messages for you at this phone number? *

Yes No

Address *

Line 1

Line 2

City

State

Zip Code

Country

Family Doctor *

Family Doctor Phone *

Emergency Contact *

Emergency Contact Phone *

Relation to Emergency Contact *

How did you hear about us? *

Direct Billing Plan Holder Name *

Policy Number *

ID Number *

Credit Card Number *

Expiry Date *

CVV (3 digits on back of card) *

Please list your primary health concerns AND when they started *

Please list all medications including the dose, reason and when you started taking *

Please list any supplements you are taking including the dose, reason and when you started taking *

Allergies (if none, write "none) *

By Checking the boxes below: *

I certify that the above information is correct to my knowledge: I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above: I understand that my personal and medical information is confidential and will not be disclosed to third parties without my written permission: On a case-by-case basis, with written or verbally documented consent, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring physician as necessary for my beneficial treatment: I consent and agree to the terms of the cancellation policy (I must provide 48 hours notice or I am charged the cost of the scheduled visit up to $50):

Submit

Naturopathic Intake Form

Naturopathic Doctor Intake Form