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Chiropractic, Massage & Acupuncture
Naturopathic
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Adult Intake Form
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Chiropractors
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Dr. Katherine MacAdam, BScKin, DC, MSc, ACC, FCCSS(C).
Dr. Maggie McKeough BSc, DC, Medical Acupunture
Massage Therapists
>
Laura Dwyer, RMT
Cassie Hilani, RMT
Adam Blackwood, RMT
Morgan Nearing-Deveaux, RMT
Naturopathic Doctor
>
Dr. Cassandra Connolly, BSc, ND
Acupuncturist
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Nicole Stallard, RAc, DAc
Reception Staff
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Please complete this form and return before your first visit
Naturopathic Doctor Intake Form
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Please list your primary health concerns AND when they started
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Please list all medications including the dose, reason and when you started taking
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Please list any supplements you are taking including the dose, reason and when you started taking
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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
Services
Chiropractic
>
Techniques and Therapies
Custom Orthotics & Footwear
Massage Therapy
>
Massage Therapy Treatment Options
Naturopathic Medicine
>
Vitamin & Nutrient Injections
TCM Acupuncture
Yoga
Mental Performance
Book An Appointment
Patient Intake Forms
Chiropractic, Massage & Acupuncture
Naturopathic
>
Adult Intake Form
Meet Our Team
Chiropractors
>
Dr. Katherine MacAdam, BScKin, DC, MSc, ACC, FCCSS(C).
Dr. Maggie McKeough BSc, DC, Medical Acupunture
Massage Therapists
>
Laura Dwyer, RMT
Cassie Hilani, RMT
Adam Blackwood, RMT
Morgan Nearing-Deveaux, RMT
Naturopathic Doctor
>
Dr. Cassandra Connolly, BSc, ND
Acupuncturist
>
Nicole Stallard, RAc, DAc
Reception Staff
FAQs
Contact
Gallery
Videos
Excercises