Naturopathic Treatment

Date

Name

First NameLast Name

Date of Birth

Date

Age

Gender

Address

Street Address

Street Address Line 2

CityProvince

Postal Code

Home Phone Number

Please enter a valid phone number.

Cell Phone Number

Please enter a valid phone number.

Emergency Contact Information

First Name

Last Name

Phone Number

Email

example@example.com

What is your preferred method of contact?

EmailCell phoneHome phone

I would like to sign up for Dr. Tijoriwala, ND's FREE health and wellness newsletter.

YesNo

Do you have naturopathic insurance coverage?

YesNo

If yes, who is your insurance provider?

Who is your family doctor?

Family doctor phone number:

Please enter a valid phone number.

Family doctor fax number:

Please enter a valid phone number.

How did you hear about our clinic?

Other healthcare providers you are seeking?

	What are your other health concerns in order of importance?
1
2
3

	What are your main goals for treatment?
1
2
3
4

	Please list any allergies (food, drugs and environmental)
1
2
3

	Please list current medications and dosages
1
2
3

	Please list current natural health products, supplements, herbs and homeopathic remedies:
1
2
3
4

	Please list any lab work, X-ray, MRI/CT Scans, ultrasound or other studies you have in the last year:
1
2
3

Privacy Policy

The Clinic understands the importance of protecting your personal information. Below is an outline of how our office is using and disclosing of your information.

The office will collect, use and disclose only necessary information about your for the following purposes:

To collect information for assessments conducted by our practitioners
To collect fees for services and dispensary purchases
Seminars, workshops and surveys to promote patient education (optional)

Your information will be disclosed to the following individuals:

All healthcare practitioners employed at The Clinic
To any emergency service personnel dispatched if one's life is endangered

We will only share your information with your consent. Storage, retention and destruction of your personal information complies with existing legilsation and privacy protocols set out by the College of Naturopaths of Ontario (CONO) and Ontario's Personal Health Protection Act (PHIPA).

If you understand the following, please write your full name and sign below:

First NameLast Name

Signature

Date

Informed Consent

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 spirtual aspects of the individual. Gentle, non-invasive techniques are generally used in order to stimulate the body's inherent healing capacity. Your visit may consist of thorough case hiustory and a screening physical examination. Treatments recommended include botanical medicine, Traditional Chinese Medicine and acupuncuture, homeopathy, clinical nutrition, hydrotherapy and physical therapy such as spinal adjustments, exercises and massage.

It is important that I am informed of any diseases that you are suffering froma dn if you are on any medication or over the counter drugs, supplements or herbal products. If you are pregnant, become pregnant or are breast-feeding, please let your doctor know immediately.

The health risks associated with naturopathic treatment may include but are not limited to: aggravation of pre-existing symptoms; alergic reactions to supplements or herbs; bruising or injury from acupuncture; fainting or pucturing of an organ with acupuncture needles. Results are not guaranteed and not all risks and complications can be anticipated and explained.

Naturopathic medical care is not covered under OHIP but may be covered by your extended health insurance. Please check with your plan. Direct billing is available at the clinic for most insurance companies.

I understand:

The clinic does not guarantee treatment results and naturopathic therapies may take time to improve my condition
That my Naturopathic Doctor, Dr. Tanvi Tijoriwala, ND is not mutually exclusive from any treatment or advice that I may be receiving now or in the future from another licenses care provider.
I am at liberty to seek or continue medical care from a physician or surgeon or other health care provider qualified to practice in Ontario. No employee, agent, or anyone elese under the clinic's direction or control is suggesting or recommending to me to regrain from seeking or following advice of another licensed health care provider
That I am responsible for the fees incurred during care and treatments
That I am free to withdraw my consent and to discontinue my treatment at any time
I also confirm that I have the ability to accept or reject this care of my own free will and I am not an agent of any private, local, provincial, or federal agency attempting to gather information without stating

By signing the intake form, you are agreeing to the above terms and consent to treatment By Dr. Tanvi Tijoriwala, ND

I intend this consent to apply to all present and future naturopathic care.

If you understand the following please write your full name and sign below:

First NameLast Name

Signature of Patient or Guardian

Date

Personal Information and Medical History: