Please download and complete your intake form as well as your informed consent.
Intake Form (all practitioners)
Informed Consent (Adult)
Informed Consent (IV Therapy)
Informed Consent (IV High Dose Vitamin C)
Naturopathic Intake (Pediatric)
Informed Consent (Pediatric)
Registered Massage Therapy
Registered Massage Therapy Informed Consent
A Few of Our Important Policies…
For the comfort and safety of our clients and staff, we ask that you please refrain from using scents while visiting the clinic. Appointments may be re-scheduled at the time of arrival if this policy is not respected. We appreciate you understanding.
Out of respect for our practitioners and other clients, all appointments require 24-hours notice for cancellation. Cancellations provided with less than 24-hours notice will be subject to a fee.
Personal Health Information Protection Act
The Ontario Government has legislation, the Personal Health Information Protection Act (PHIPA) that came into effect on November 1, 2004. This act has been established to set out rules for the collection and utilization of information that is collected about patients.
Collection of Personal Information
We collect personal health information about you. We collect this information either from you directly or from the person acting on your behalf (i.e a parent). The information that we collect may include your name, date of birth, address, health history, records of your visits and the care that you received. Occasionally, when we have received your consent, we receive and collect information about you from other sources.
Use and Disclosure of Personal Health Information
We use and disclose your personal health information as follows:
To treat and care for you.
To conduct risk management activities.
To conduct quality improvement activities, such as completing surveys.
To compile statistics to improve our programs and services.
To comply with legal and regulatory requirements.
To fulfill other purposes permitted or required by law.
It’s Your Choice
With regard to the above uses and disclosures of your personal health records, you have a choice. You may access, correct, or request a copy of your personal health records at any time.
Our Pledge to Protect Your Personal Health Information
The following are a list of pledges to you that we have made to protect your personal health information:
We will take steps to protect your personal health information from theft, loss and unauthorized access, copying, modification, use, disclosure and disposal.
We will conduct audits and complete investigations to monitor and manage our privacy compliance.
We will take steps to ensure that everyone who performs services for us protects your privacy and only uses your personal health information for the purposes you have consented to.
If you have questions about our policy, please let us know.