Intake Form

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Intake Form

The ART of LIFE NATURAL HEALTH CENTRE
121-885 Don Mills Rd. |North York, ON, M3C 1V9
416-449-6747 | office@theartlife.ca

Name: Last

First

Date of Birth *dd/mm/yyyy

Sex

Phone (Cell)

Phone (Work)

Phone (Other)

Email

Address : Apt #

Street #| Name

City

Postal Code

Emergency Contact

Phone

Agree to Receive Promotional Material

Family Physician Name

Phone #

Referred by Doctor (Name)

Referred by Friend (Name)

How Did You Hear About Us?

If Female: Are You Currently Pregnant?

Your General State of Health

Please Indicate Any Serious Illnesses, Injuries, Hospitalizations (with approximate dates)

Do You Have Any Allergies?

Please Specify

Frequently Using The Following?

Birth Control

Alcohol

Tobacco

Recreational Drugs

List of Medications (Prescriptions, Vitamins, etc.)

Medical History (Please select applicable)

Do You Get Regular Tests Done? (Pap, Blood, etc)

Yes

No

Do You Have Any Food Intolerances?

Yes

No

Any Additional Information You Wish to Share or Inquire About.

I Acknowledge That Payment For All Treatments & Services at The Art of Life Health Centre Is My Responsibility, Regardless of Limited Percentage Coverage By Insurance or Claim Rejection During Submission. Appointments Must Be CANCELLED OR RESCHEDULED AT LEAST 24 HOURS IN ADVANCE. Late Cancellations or Missed Appointments Will Be Subjected to CANCELLATION FEE ( Amount Depends on Service).

Agree

If you are human, leave this field blank.

“By clicking SUBMIT you consent to receiving SMS messages.” * “Messages and Data rates may apply. Message frequency will vary” * “Reply Help to get more assistance” * “Reply Stop to Opt-out of messaging”

No mobile information will be shared with third parties for marketing or promotional purposes. All the above categories exclude text messaging originator opt-in data consent; this information will not be shared with any third parties

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