Intake Forms

Please complete the appropriate form before your initial appointment. You may print and complete the PDF, save and e-mail it to [email protected] (strictly confidential). Alternatively, you may print the forms and bring them completed to your initial visit. Or, scroll down below to fill out our online form.

Your time and honesty in completing the forms is appreciated. By thoroughly completing these forms, we can better understand you as a person and help you meet your goals.

If you are not able to print the forms, please arrive 15-20 minutes early to complete them before your visit. 

Thank you!

Online Intake Form – Naturopathic & Nutrition Patients

New patients who have an initial visit scheduled with Dr. Leigha, Dr. Lynne (Naturopathic Doctors) or Natalie (Holistic Nutritionist) may complete their intake forms online here.

Your time and honesty in completing the forms is appreciated. By thoroughly completing these forms, we can better understand you as a person and help you meet your goals!

Please make sure you receive confirmation that the form has been submitted when you have complete it.

True Roots Intake Form

Patient Information

Contact Information

Emergency Contact Information

Other Healthcare Providers

Clinic Information

Health Concerns

Medication/Supplement:

Please list any prescription medications, over the counter medications, vitamins or other supplements you are taking with dosages and frequency. If you do not take any medications or supplements, please write 'none' in the first blank.
Do you use or have any of the following?

Allergies & Sensitivities

Context of Care Review

What are your top three expectations in working with us?

General Information

Please rate the following on a satisfaction scale of 0-10, 10 being the most satisfied:

Food Log

Initial - $190, Regular Follow Up (15-30 mins) - $95, Extended Follow Up (30-45 mins) - $142.50 Additional treatments and testing are variable in cost and will be discussed with you.
I understand my appointment time is reserved just for me. A late cancellation or missed visit leaves a schedule gap that could have been filled by another patient. As such, I agree to provide at least 24 hours notice for any cancellations or changes to my appointment. If I provide less than 24 hours notice, or miss my appointment (‘no-show’), I will be charged for the full cost of the missed appointment.
Initial - $190, Regular Follow Up (15-30 mins) - $95, Extended Follow Up (30-45 mins) - $142.50
Additional treatments and testing are variable in cost and will be discussed with you.
Initial Nutritional Consultation - $150 (90 mins), 30 minute Nutritional Consultation - $75, 45 minute Nutritional Consultation - $100

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