You can always press Enter⏎ to continue
Client Intake
Client Intake
Please answer the following questions.
Client Intake
  • 1
    Press
    Enter
  • 2
    Press
    Enter
  • 3
    Press
    Enter
  • 4
    Press
    Enter
  • 5
    Press
    Enter
  • 6
    • Email
    • Text
    • Phone
    Press
    Enter
  • 7
    Press
    Enter
  • 8
    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.
    Press
    Enter
  • 9
    Press
    Enter
  • 10
    Please be sure they are relevant to the service or program you have registered for.
    Press
    Enter
  • 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

    Press
    Enter
  • 12
    Press
    Enter
  • 13
    Press
    Enter
  • 14
    • Legal guardian
    • Parent
    • Other
    Press
    Enter
  • 15
    Press
    Enter
  • 16
    IMPORTANT: In-Person appointments are currently suspended due to the ongoing and changing restriction associated with the Government response to SARS-CoV-2. Remote appointments are still available and just as effective as In-Person appointments. Should you still prefer in-person appointments I can add you to a contact list and book you in as soon as in-person appointments are available.
    Press
    Enter
  • 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. 

    Press
    Enter
  • 18

    Consulting & Privacy Agreement (Signature Required)

    I,           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
             
    Date:       Pick a Date    

    Press
    Enter
  • 19

    Consent to Use Electronic Communication (Signature Required)

    I           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.  

               Pick a Date    

    Press
    Enter
  • 20
    Press
    Enter
  • 21
    Press
    Enter
  • Should be Empty:
Question Label
1 of 21See AllGo Back
close