Initial Nat-med consultation client form

NATURO

Name *

First

Last

Age *

Date of Birth *

Email *

Name *

First

Last

Relationship to you

Medical doctor (if you have one)

Consultant or specialist (if you have one)

Holistic therapist

Other person involved in your case

If you have joined a package your Naturo-medicine practitioner may need to open channels of communication between holistic and medical practitioners who you are working with. This is for the best integrated approach. Do you give our team permission to contact these persons if needed *

Diagnosed conditions (this is a condition officially diagnosed by your medical doctor)

Please explain in your own words any symptoms and medical conditions you are currently experiencing.

1. Condition / Symptoms

2. Condition / Symptoms

3. Condition / Symptoms

What do you want to prioritise in this naturo-medicine appointment?

I agree that Real Naturo appointments or packages has a no refunds policy. Any appointments that are cancelled less than 24 hours in advance will charged in full and will no incur a refund. Only 3 rescheduling of Naturo-medicine appointments and naturo-therapy sessions can occur in each package. *

I agree

Thank you for visiting Real Naturo and for using our naturopathic services. Our practitioners are insured naturopathic practitioners. Your country or state may not yet offer licensure for naturopaths. Therefore, we can not be your primary care provider. It is recommended that you maintain a relationship with, and, when necessary, seek treatment from, a licensed primary care provider. All Real Naturo practitioners and representatives are acting in a health consultant capacity only. We do not treat, cure, diagnose, or prevent any disease or medical diagnosis. You are wilfully accepting a naturopathic appointment or a juice cleanse from Real Naturo. You acknowledge that Real Naturo is not acting in any capacity as a licensed physician, but is providing general wellness consulting. You acknowledge that Real Naturo does not diagnose or treat physical or mental ailments, diseases of psychological conditions. Real Naturo provides general wellness consultations that may or may not confer health benefit to the individual. You acknowledge that Real Naturo may share my personal details with other licensed practitioners, physicians and therapists to assist with treatment. Lab work that is reviewed or requested by the Practitioner is done to assist in creating a plan to provide naturopathic support. A medical diagnosis must be sought from a licensed healthcare provider. Any supplement, herbal or vitamin recommendations obtained from Real Naturo, Real Naturo does not claim that such products treat, cure or prevent physical and/or mental ailments or disease. The effects of the products available Real Naturo have not been evaluated by the Food & Drug Administration. You understand that a record will be kept of the health consultation provided. This record will be kept confidential and will not be released to others unless so directed by you or your representative or unless it is required by law. You understand that your consultation record will be kept for a minimum of three, but no more than ten years after the date of your last visit. You understand that information from your consultation record may be analysed for research purposes, and that your identity will be protected and kept confidential. You understand that any questions your have will be answered by your consultant to the best of their ability.

I agree

Email *

Message

Key Links

Main Navigation

Search Real Naturo