RENH Naturopathic Intake for Rivers Edge Natural Health

Intake Form & Waiver for Services

Your answers are strictly confidential and will allow us to have a better understanding of who you are and your main goals and health concerns.
Name*

First NameLast Name
Date of birth*

MonthDayYear
Gender*
Occupation
How did you hear about Katherine Lehman, ND & DTR?
If you were referred by someone, please list their name
Contact Information
Address:*

Street Address

Street Address Line 2

CityState

Postal / Zip CodeCountry
E-mail that we will use to regularly communicate with you
Can we contact you over email regarding your appointments and/or questions you may have?
Preferred Cellular phone number for voice and/or text communication*

Area CodePhone Number
In case of emergency...
Emergency Contact:

First NameLast Name
Relationship
Contact Number

Area CodePhone Number

Naturopathic Visit
What are your reasons for coming to see a Naturopathic Doctor? Please list your concerns or treatment goals, in order of importance to you*
Have you ever seen a Naturopathic Doctor before?

YesNo

Please quickly rate your level of satisfaction with the following areas of your life.

(1 star = not satisfied, 5 star = very satisfied)
Health
Click to edit
Diet
Click to edit
Occupation
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Fitness Level/Physical Activity
Living/Home Environment
Family and Friends
Romantic partnership/Significant Other
Is there anything else you would like to add that you feel is important and has not been covered?

Treatment Waiver
Full Name(s) of ANY and ALL Family Members Seen at Rivers Edge or that WILL BE Seen in the Future
I, the undersigned person(s), do agree and understand that the practitioners of Rivers Edge Natural Health are NOT medical doctors, chiropractors, registered nurses, licensed practical nurses, licensed physical therapists/physiotherapists, or licensed counselors. I understand and agree that they only claim to be, respectfully, a Doctor of Naturopathic Medicine, a Licensed Massage Therapist, Certified Natural Health Practitioners (CNHP's), a Dietetic Technician Registered (DTR), a Christian Family Preservation Child/Family Advocate, and Ordained Ministers.

I affirm that I have come to this agency to avail myself of the respected services offered and have not, nor will I ask these practitioners to do anything illegal, nor anything that is against the practitioner's personal or professional values and/or ethics. Further, I release them from any and all liability arising out of claims or matters that relate, in whole or in part, to my sessions with Rivers Edge Practitioners.
Please sign and date below
Today's Date

MonthDayYear
Thanks for taking the time to complete this intake form and We look forward to meeting you!
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Intake Form & Waiver for Services