Patient Intake Form

By submitting this form I consent to the following:

I have informed of all known physical and medical conditions and will provide updated information if my health condition is to change in the future.

I am aware that along with the many benefits of treatment, there is also a small risk of injury. I will discuss the benefits and risks as well as the nature of the treatment and the conditions that will be addressed at each appointment.

I consent to the treatments offered or recommended to me and intend this consent to apply to all future care.

Cancellation Policy:

In the event that I cannot keep my scheduled appointment, I agree to provide 24 hours notice of changes. If I do not attend an appointment and have not given the required notice, I agree to reimburse the practitioner following the fee schedule.

This is a confidential record of your medical history. Information contained in it will not be released to any person unless authorized by you.

Alternatively, an intake form can be downloaded as a PDF here.

 

HomeCellWork

HomeCellWork

Contact

403-669-2439

“The Healthy Path is convenientlly located in the Killarney area of Calgary, Alberta, Canada.”

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