Name * First Name Last Name Phone (###) ### #### Date of Birth MM DD YYYY Email * Active Medications (and recent w/in 6 months) * Allergies (list all or none) * Supplements (list or none) * Medical History (last labs, imaging, or visit) * Subject * Medical History Agreement: * By checking this box, I understand that any false information provider can lead to an unintended outcome. This "check"-agreement is an agreement that I have provided my full medical history, as requested. Consent to treat: * By checkng this box, I agree that I have read and understand the "Consent to Treat" information provided; and if I choose not to or forgo reading the mentioned consent I agree to arbitration of any finical or malpractice claim within the statute of said claim. by checking this bos i agree to contact the clinic One Body Naturopathic Medicine Inc. before agreeing with any and all disagreement or questions with my/this agreement.. Signature (print name) *
