Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Phone number *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

If the guest/patient is a minor, please put the name of the accompanying parent/guardian

First Name

Last Name

Please select all that apply to you *

Compassion Health is for individuals and families experiencing financial limitations/challenges. You must select one or more that applies to you and bring proof to your appointment.

Unemployed / on Employment Insurance (EI)

Ontario Disability Support Program

Ontario Works

Single parent

Newcomer

Refugee

Homelessness

Other

Which healthcare provider(s) would you like to see? (select all that apply) *

Each appointment is approximately 30 - 60 minutes

Naturopathic Doctor / Lifestyle medicine

Nutritionist

Psychotherapist

Marriage/Communications counselor

Certified Personal Trainer

Hair cut

Media Release *

I understand and accept that photos and videos will be taken ONLY in public spaces of the Compassion Health clinic site. Photos/videos WILL NOT be taken in your consultation rooms during your appointment

Yes

Informed consent *

As a patient of Compassion Health Toronto and its partner healthcare providers, I am at liberty to seek or continue medical care from a medical doctor or other health care provider. With this knowledge I voluntarily agree to the diagnostic and therapeutic treatments offered at Compassion Health. 1. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time. 2. I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others without my consent, unless required by law. 3. I understand that I may look at my medical record at any time and may request a copy of it 4. I understand that the healthcare provider will answer any questions I have to the best of his/her ability. 5. I understand that the results are not guaranteed. With this knowledge I voluntarily agree to the diagnostic and therapeutic treatments offered. I acknowledge that I have been informed of, and fully understand the above:

Yes