Client Intake

1

What is your name?* This field is required.

First Name

Last Name

2

What is your birth date: year, month, day?* This field is required.

Year/Month/Day

3

What is your gender?* This field is required.

4

What is your email address?* This field is required.

example@example.com

5

What is your phone number?* This field is required.

Area Code

Phone Number

6

How would you prefer me to contact you?* This field is required.

7

How did you hear about my services?* This field is required.

8

What service are you registering for?Individuals seeking “General Consulting” understand that this is a basic consult for general nutrition/supplement/botanical remedy questions and will not address disease-specific questions or go into detailed personalized advice.

General Consult, 30 minutes

Client Follow up, 30 minutes

Individualized Consulting (2 appointments)

9

What question(s) would you like addressed during your consult?* This field is required.

10

Health Concerns and or goals: List goals or health imbalances you would like to work on?* This field is required.Please be sure they are relevant to the service or program you have registered for.

11

Be sure to provide a list of all medications at your appointment, including supplements, sports supplements, and/or herbal remedies. If you are taking supplements or herbal remedies be sure to provide the brand and specific name of the item you are taking.

For remote appointments (phone, virtual chat) please send your list via email to danaclark@fromtherootsholistic.ca

12

If you have any allergies or sensitivities please list them below.

13

Are you filling out this form for a minor or someone who requires a legal guardian?* This field is required.

No

Yes

14

If yes what is your relationship to the minor or individual?

15

What is your name

First Name

Last Name

16

How would you like to have your appointment/sessions?* This field is required.For in person appointments , you will receive an COVID-19 screening document sent to you via email 48 hours prior to your appointment. This needs to be filled out 24 hrs prior to your appointment.

Online

Over the phone

In-Person

17

Appointment Terms & Conditions (please read)

All information provided in this form is confidential and will not be released to anyone.
Individuals seeking Individualized Consulting (in-person or online) will be booked in for two initial appointments. One health & lifestyle assessment and one overview appointment. The fee for both appointments is a packaged fee to be paid at the first appointment.
Individuals seeking “General Consulting” understand that this is a basic consult for general nutrition/supplement/botanical remedy questions and will not address disease-specific questions or go into detailed personalized advice. Those who would like personalized and/or disease-specific consulting should register for the Individualized Consulting where a full assessment can be taken.
Body Composition Measurements are not recommended for individuals who have a history of Body Dysmorphic Disorder(s).
For Health Benefit Claims, you are encouraged to inquire and confirm that you are covered for my services (Registered Nutritional Consultant and/or Certified Natural Health Practitioner) and to submit receipts to your insurance company.
Once your appointment is booked, it is your responsibility to attend this appointment and any future appointments or cancel/reschedule a minimum of 24 hours prior to your appointment. Should you not cancel/reschedule within this time frame you will be charged a $10.00 fee.
All fees are non-refundable.

By clicking next, you are agreeing to all the above.

18

Consulting & Privacy Agreement (Signature Required)

I,    First Name     Last Name    consent to receive health consulting & professional advice from Dana Clark CNHP CHC CHN CLE.

I further understand and agree that in order for Dana to assist with my present state of health that I must cooperate with her and follow through on programs she has designed for me to attain and/or maintain better health.

I further understand that Dana will keep my medical information confidential unless an order by law dictates the relinquishment of such personal medical files.

I will provide all necessary medical information required by Dana to aid in the assistance I have requested from Dana so that the methods prescribed or suggested do not conflict with the treatment I am receiving from other medical sources.

I further agree that the advice provided by Dana is in accordance with her formal academic training, continued education, and science-based research. and is not to be considered the treatment or suggested treatment of a Medical Doctor.

I acknowledge that I am responsible to book any follow-up appointments and to cancel any appointment I cannot attend within 24hrs. Should I cancel within this time frame or show up for an appointment without proper cancelation I understand I will be billed $10.00 and am fully responsible to pay this fee.

I agree to the terms of services
Signature
Date:       Date

19

Consent to Use Electronic Communication (Signature Required)

I First Name Last Name acknowledge that in consenting to have Dana Clark CNHP CHC CHN CLE, communicate with and/or provide services through online platforms. I am aware of the following:
While Dana Clark will use reasonable means to protect the security and confidentiality of information sent and received using electronic communications, because of the risks outlined below, Dana cannot guarantee the security and confidentiality of electronic communications:

The use of electronic communications to discuss sensitive information can increase the risk of such information being disclosed to third parties.
Despite reasonable efforts to protect the privacy and security of electronic communication, it is not possible to completely secure the information.
Online services may have a legal right to inspect and keep electronic communications that pass through their system.
Electronic communications can introduce malware into a computer system, and potentially damage or disrupt the computer, networks, and security settings, though Dana Clark has made every precaution to avoid this, including anti-virus programs/firewalls.
Electronic communications are subject to disruptions beyond the control of Dana.
Electronic communications may be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of Dana Clark or the client.
Even after the sender and recipient have deleted copies of electronic communications, back-up copies may exist on a computer system, though Dana tries to avoid this.
There may be limitations in the services that can be provided through electronic communications.

Signature Date

20

How would you like to pay for your appointment or program?* This field is required.For e-transfer and credit card payments you will be invoiced via email. All credit card payments via the email are secured, you can however pay in person or over the phone as well.

Cash (for in person appointments only, please bring the exact amount)

E-transfer to fromtherootsholistic@gmail.com

Credit card

21

Do you require a formal receipt to submit to any Health Benefits Coverage Plan?* This field is required.

yes

no