Initial Client Intake Form

Congratulations on taking your first step towards improving your health! Thank you for choosing Elle Eastwood Naturopathy.

Name *
Are you happy to receive our newsletter? *
(name, dosage and frequency)
Your Medical History
Please check any relevant symptoms:
Respiratory System
Female Health
General Health
e.g hypertension, diabetes, cancers, stroke, depression etc
Consent *
I understand Elle Eastwood is a naturopath, not a medical doctor. I give permission for my personal information to be kept on file for the purpose of naturopathic treatment. I understand all reasonable steps will be taken to keep my personal information confidential.

Cancellation Policy. While I understand things can arise at the last minute, please be courteous and notify us by phone or email if you are unable to attend an appointment with at least 24 hours notice prior to your scheduled appointment. This time can then be assigned to someone else. Please note that if you miss an appointment or reschedule inside the 24 hours a fee of $25.00 will be charged.