Erin Mills Optimum Health is now open for all patients, with Updated Health and Safety procedures in place.
Erin Mills Optimum Health
905-828-2014
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Patient Forms

Chiropractic Intake Form

Complete Form

Chiropractic Child Intake Form

Complete Form

MVA Info Form

Complete Form

Naturopathic Intake Form

Complete Form

Naturopathic Pediatric Intake Form

Complete Form

Massage Intake Form

Complete Form

Chiropody Intake Form

Complete Form
Chiropractic Intake Form

Health Questionnaire

Name*
Gender*
Date
Address
City
Postal Code
Date of Birth
Status
Phone*
E-mail address*
Occupation
Name of Spouse
Number of Children
Ages
Who referred you to our office?
Have you been to another Chiropractor?
About Your Health

“The beauty about Chiropractic is the fact that it works with natural means. It puts nothing new into the body, nor does it take away any natural gland or organ. Chiropractic simply releases life forces within the body, sets free rivulets of energy over nerves, and lets nature do her work in a normal matter.” B.J. Palmer

Is this a wellness check-up or do you have a specific health concern?
Describe your major complaint
How long has this been going on?
Is the condition interfering with
Have you consulted anyone else for this condition?
What kind of treatments or therapies have you tried to get rid of this problem?
Other symptoms you have experienced in the last 6 months
Many spinal problems can date back to childhood injuries and even the birth process itself
Growth & Development (Please fill out to the best of your knowledge)
Current Health Habits
Sleep position?
Please Rate Your Current Stress Levels
Occupational
Mental
About Your Care

Chiropractic provides three types of care. The first is Initial Intensive Care, which corrects the most recent layer of Spinal and Neurological damage. This care usually reduces or eliminates the symptoms. Then begins Corrective Care, which corrects the years of damage that may have occurred. Once the spine and your health are functioning at its optimum level we provide Wellness Care, which maintains and further enhances your health.

The purpose of our Chiropractic Office is to support and empower you in achieving your optimum health

Chiropractors locate, analyze and correct subluxations (spinal misalignments which cause nerve interference).

Chiropractic improves the nerve supply to your entire body and allows the Innate Healing Power of your Body to work at maximum efficiency to restore, maintain and promote health.

Chiropractic care is considered to be one of the safest and most effective forms of health care. As in all health care, however, there are some very slight and minimal risks to chiropractic care, including but not limited to, minor muscle strains and sprains, disc injuries and strokes. Tests will be performed on you to minimize this risk and the appropriate chiropractic adjusting techniques will be applied.

The doctors and/or staff will always be available to answer questions and discuss the nature and purpose of chiropractic procedures. Results cannot be guaranteed, as every person is unique.

Consent for Personal Information
I agree to Erin Mills Optimum Health collecting and using personal information about me as set out in their Privacy Policy which I have an opportunity to review at any time.

We will gladly assist you in understanding your insurance coverage, but you agree that you are responsible for your account.

  • Fees:
  • Initial Assessment:$90.00
  • Adjustment Fee:$50.00
  • Re-Assessment Fee:$65.00 (Resuming care after a year or more)
  • X-ray Fee (if necessary):$100.00
  • Surface EMG Fee (if necessary):$40.00

I have read the above and consent to care at the Erin Mills Optimum Health.

Date
Parent/Guardian's Name
Parent/Guardian's Signature
Clear
Chiropractic Child Intake Form

Pediatric Health Questionnaire

(Birth, up to 10 years old)

Name*
Gender*
Date
Date of Birth
Address
City
Province
Postal Code
E-mail address*
Phone*
Parent/Guardian Names
Medical Doctor
Have you been to another Chiropractor?
Who referred you to our office?
About Your Health

“The beauty about Chiropractic is the fact that it works with natural means. It puts nothing new into the body, nor does it take away any natural gland or organ. Chiropractic simply releases life forces within the body, sets free rivulets of energy over nerves, and lets nature do her work in a normal matter.” B.J. Palmer

Would this be a wellness check-up or is there a specific health concern your child is experiencing? Please describe
How long has this persisted?
Is the condition interfering with
Have you consulted with any other health care professional regarding this condition?
What kind of treatments or therapies have you tried to get rid of this problem?
Indicate if any of the following has occurred from the age of 5 years to present
Which of the above problems are the worst?
List any medications that your child is currently taking
Is there anything else that you feel we should be aware of?
Teeth Problems
Eye problems
Hearing problems
Physical Activity
Sleeping position?
History of Mother’s pregnancy and baby’s delivery
Did you carry to full term?
Describe any complications and when they occurred
Additional information
About Your Care

Chiropractic provides three types of care. The first is Initial Intensive Care, which corrects the most recent layer of Spinal and Neurological damage. This care usually reduces or eliminates the symptoms. Then begins Corrective Care, which corrects the years of damage that may have occurred. Once the spine and your health are functioning at its optimum level we provide Wellness Care, which maintains and further enhances your health.

Chiropractors locate, analyze and correct subluxations (spinal misalignments which cause nerve interference).

Chiropractors locate, analyze and correct subluxations (spinal misalignments which cause nerve interference).

Chiropractic improves the nerve supply to your entire body and allows the Innate Healing Power of your Body to work at maximum efficiency to restore, maintain and promote health.

Chiropractic care is considered to be one of the safest and most effective forms of health care. As in all health care, however, there are some very slight and minimal risks to chiropractic care, including but not limited to, minor muscle strains and sprains, disc injuries and strokes. Tests will be performed on you to minimize this risk and the appropriate chiropractic adjusting techniques will be applied.

The doctors and/or staff will always be available to answer questions and discuss the nature and purpose of chiropractic procedures. Results cannot be guaranteed, as every person is unique.

Consent for Personal Information
I agree to Erin Mills Optimum Health collecting and using personal information about me as set out in their Privacy Policy which I have an opportunity to review at any time.

We will gladly assist you in understanding your insurance coverage, but you agree that you are responsible for your account.

  • Fees:
  • Initial Assessment:$90.00
  • Adjustment Fee:$40.00
  • Re-Assessment Fee:$65.00 (Resuming care after a year or more)
  • X-ray Fee (if necessary):$100.00
  • Surface EMG Fee (if necessary):$40.00

I have read the above and consent to care at the Erin Mills Optimum Health.

Date*
Parent/Guardian's Name*
Parent/Guardian's Signature*
Clear
MVA Info Form

Motor Vehicle Accident
Patient Information

In order for us to best serve you, and process your Claim promptly please provide all information as soon as possible

Patient Name*
Email*
Date of Accident
Date of Birth
Date
Car Insurance Information
Insurance Company Name
Address
City
Postal Code
Phone*
  -  
Fax Number
Policy Number
Claim Number
Contact Person
Work Information
Place of employment
Address
City
Postal Code
Phone Number
Fax Number
Your work insurance information (extended health)
Insurance Company Name
Address
City
Postal Code
Phone Number
Fax Number
Employee Policy Number
Employee Claim Number
Your spouse’s work insurance
Spouse’s Name
Date of Birth
Insurance Company Name
Address
City
Postal Code
Employee Policy Number
Employee Claim Number
Please give a brief description of the accident and what happened to you. Please describe any injuries as a direct result of the accident

We will gladly assist you in understanding your insurance coverage, but you agree that you are responsible for your account.

I have read the above and consent to care at the Erin Mill’s Chiropractic Centre.

Date*
Patient’s Name*
Patient’s Signature*
Clear

* Please provide our office with any information forms concerning your accident that need to be filled out.

Naturopathic Intake Form

Naturopathic Intake Form

Today’s Date
Date of Birth
First Name*
Last Name
Address
City
Province
Postal Code
Phone*
Can we leave messages
Email*
Emergency Contact
Medical Doctor
Dr’s Fax and Phone Number
How did you hear about us?
This record of your medical history is confidential. Information it contains will not be released to any person unless you authorize me to do so. To review our privacy policy click on this link.
Please list KNOWN ALLERGIES (food or drug) or “MEDIC-ALERT” CONDITIONS
Medications/Supplements taken
Is your health currently getting better, worse, or staying the same?
What are the most significant measures which you have taken to date, to improve your state of health?
Prioritize your health-related concerns, below.
What do you feel your weakest organ system is, and why? (heart, kidneys, lungs, etc.)
What is the quality of your sleep?
How many hours do you sleep?
Difficulty falling or staying asleep?
Do you wake frequently?
Do you wake refreshed?
Have you had any significant dental work?
Have you had any recent vaccinations?
Do you smoke?
Have you quit in the last 5 years?
Do you drink alcoholic beverages?
Do you drink caffeinated beverages?
Do you do any sort of stress-relieving activities? How do you cope with stress?
Please check the appropriate boxes
General
Skin and Hair
Eyes Ears Nose Throat
Cardiovascular
Muscle, Bone & Joints
Respiratory
Gastrointestinal Stomach
Pancreas
Leaky Gut
Colon FLora
Liver
Neurological
Genito-Urinary
Adrenal Fatigue
Adrenal Stress
Female
Date of last Pap
Age of first menses
Menopausal
Age of last menses
Pregnant?
Male
Family History
Mother
Her Mother
Her Father
Father
His Mother
His Father
Children
Siblings
Additional Studies
Please check the appropriate boxes if you are interested in any of the following tests/treatments
CONSENT FORM
INFORMED CONSENT TO NATUROPATHIC TREATMENT

Naturopathic medicine is the treatment and prevention of diseases by natural means. Naturopathic Doctors (N.D.’s) assess the whole person, including physical, mental, emotional and spiritual aspects of the individual. N.D.’s use a variety of therapeutic approaches, either alone, or in combination. These include nutritional and lifestyle counseling, nutritional supplementation, Asian medicine and acupuncture, botanical medicine, homeopathy and physical medicine.

This is to acknowledge that I have been informed and I understand that:

  1. any treatment or advice provided to me as a patient of Kirsten Almon N.D., Ashley Chauvin N.D., and Dr. Kajal Chohan N.D. is not mutually exclusive of any treatment or advice that I may now be receiving or may in the future receive from another licensed health care provider;
  2. I am at liberty to seek or continue medical care from a physician or surgeon or other health care provider qualified to practice in Ontario;
  3. Kirsten Almon N.D., Ashley Chauvin N.D., and Dr. Kajal Chohan N.D. have not suggested or recommended to me to refrain from seeking or following the advice of another licensed health care provider;
  4. The treatment and therapies rendered or recommended by Kirsten Almon N.D.,Ashley Chauvin N.D., and Dr. Kajal Chohan N.D. may be different from those usually offered by a medical doctor or other licensed health care provider.
  5. There are some risks, however rare, to Naturopathic Medicine. These include but are not limited to:
    • aggravation of pre-existing symptoms,
    • allergic reaction to supplements or herbs,
    • pain, bruising or injury from acupuncture,
    • fainting or puncturing of an organ with acupuncture needles.

I declare that I have received a full and complete explanation of the treatment or services that I may receive at the Erin Mills Optimum Health by Kirsten Almon N.D., Ashley Chauvin N.D., and Dr. Kajal Chohan N.D. hereby authorize and consent to treatment by Kirsten Almon N.D., Ashley Chauvin N.D., and Dr. Kajal Chohan N.D. I intend this consent to apply to all my present and future naturopathic care.

Signature of patient*
Clear
Name of patient printed*
Date*
NATUROPATHIC FEE SCHEDULE

I understand that the fees are as follows:

  • VISITFEE
  • INITIAL EXAM$220.00 (adult)
    $200.00 (*child)
  • Subsequent Visits$130.00 (adult)
    $120.00 (child)
  • Acupuncture & Craniosacral$130.00
  • Phone consultation$60.00

*Child is anyone under the age of 12 years.

Arranged telephone consultations with the doctor: $60.00 for up to 15 minutes.
There are separate fees for treatments involving the administration of specialized substances (e.g. B12/folic acid intra-muscular injection) based on the amount of substance used. The fee will be discussed before treatment is administered.

Extended health care benefits may also cover naturopathic treatment. Please check your plan details or call your human resources.

Please note that there is a 48-hour cancellation policy. If 48 hours notice is not given, a $60.00 missed appointment fee will be charged.

I agree to pay my account in full at the time of each visit or treatment.

I acknowledge that I may purchase products prescribed by Kirsten Almon N.D., Ashley Chauvin N.D. and Kajal Chohan N.D. from Erin Mills Optimum Health or from any health food store.

Please sign that you have read the above and you acknowledge the fee schedule.

Signature*
Clear
Date*
Naturopathic Pediatric Intake Form

Naturopathic Pediatric Intake Form

Today’s Date
Child’s Date of Birth
Child’s full name*
Sex*
Parent/Guardian’s Names
Address
City
Province
Postal Code
Phone*
Can we leave a message
Email Address*
Emergency Contact
Relationship
Weight at Birth
Present Weight
Child’s Height
Parent/Guardians’ Occupations
Who referred you to our office?
Child’s Chief Health Concerns: please include date of onset
Prenatal Health
Health at time of conception: 1-5 (5 being excellent health)
Mother
Father
Mother’s health during pregnancy
Mother’s age at the time of child’s birth
Prenatal care
Duration of Pregnancy
Did mother experience any of the following during pregnancy?
Did mother use any of following during her pregnancy?
Herbs/Vitamins/Medications
Neonatal Health History
APGAR Scores
Birth
Has your child suffered any of the following
Your child’s Diet
Vaccinations: Please check off
Allergic responses to any?
Has your child had any difficulty with the following: (Please check off)
Is your child in daycare?
How is the emotional climate of the home (happy, sad, busy etc)?
Describe the emotional disposition of your child.
Is there anything else we may have missed?
INFORMED CONSENT TO NATUROPATHIC TREATMENT

Naturopathic medicine is the treatment and prevention of diseases by natural means. Naturopathic Doctors (N.D.’s) assess the whole person, including physical, mental, emotional and spiritual aspects of the individual. N.D.’s used a variety of therapeutic approaches, either alone, or in combination. These include nutritional and lifestyle counseling, nutritional supplementation, Asian medicine and acupuncture, botanical medicine, homeopathy and physical medicine.

This is to acknowledge that I have been informed and I understand that:

  1. any treatment or advice provided to me as a patient of Kirsten Almon N.D., Aisling Lanigan N.D., Ashley Chauvin N.D., and Dr. Kajal Chohan N.D. is not mutually exclusive of any treatment or advice that I may now be receiving or may in the future receive from another licensed health care provider;
  2. I am at liberty to seek or continue medical care from a physician or surgeon or other health care provider qualified to practice in Ontario;
  3. Kirsten Almon N.D., Aisling Lanigan N.D., Ashley Chauvin N.D., and Dr. Kajal Chohan N.D. have not suggested or recommended to me to refrain from seeking or following the advice of another licensed health care provider;
  4. The treatment and therapies rendered or recommended by Kirsten Almon N.D., Aisling Lanigan N.D., Ashley Chauvin N.D., and Dr. Kajal Chohan N.D. may be different from those usually offered by a medical doctor or other licensed health care provider.
  5. There are some risks, however rare, to Naturopathic Medicine. These include but are not limited to:
    • aggravation of pre-existing symptoms,
    • allergic reaction to supplements or herbs,
    • pain, bruising or injury from acupuncture,
    • fainting or puncturing of an organ with acupuncture needles.

I declare that I have received a full and complete explanation of the treatment or services that I may receive at the Erin Mills Optimum Health by Kirsten Almon N.D., Aisling Lanigan N.D., Ashley Chauvin N.D., and Dr. Kajal Chohan N.D. hereby authorize and consent to treatment by Kirsten Almon, Aisling Lanigan, Ashley Chauvin, and Dr. Kajal Chohan. I intend this consent to apply to all my present and future naturopathic care.

Signature of Parent/Guardian's
Clear
Name of patient printed
Date
NATUROPATHIC FEE SCHEDULE

I understand that the fees are as follows:

  • VISITFEE
  • INITIAL EXAM$220.00 (adult)
    $200.00 (*child)
  • Subsequent Visits$130.00 (adult)
    120.00 (child)
  • Acupuncture & Craniosacral$130.00
  • Phone consultation$60.00

*Child is anyone under the age of 12 years.

Arranged telephone consultations with the doctor: $60.00 for up to 15 minutes.

There are separate fees for treatments involving the administration of specialized substances (e.g. B12/folic acid intra-muscular injection) based on the amount of substance used. The fee will be discussed before treatment is administered.

Extended health care benefits may also cover naturopathic treatment. Please check your plan details or call your human resources.

Please note that there is a 48-hour cancellation policy. If 48 hours notice is not given, a $60.00 missed appointment fee will be charged.

I agree to pay my account in full at the time of each visit or treatment.

I acknowledge that I may purchase products prescribed by Kirsten Almon N.D., Aisling Lanigan N.D., Ashley Chauvin N.D., and Dr. Kajal Chohan N.D. or any health food store.

Please sign that you have read the above and you acknowledge the fee schedule.

Signature of Parent/Guardian's
Clear
Date
Massage Intake Form

MASSAGE HEALTH HISTORY FORM

An accurate health history form is important to ensure that it is safe for you to receive treatment. If your health status changes in the future, please let us know. All information is confidential except as required or allowed, by law, or except to facilitate diagnosis (assessment) or treatment. You will be asked to provide written authorization for release of any information. To review our privacy policy click on this link.

Name*
Sex*
Email*
Address
City
Province
Postal Code
Phone*
Date of Birth
Marital Status
Weight
Height
Occupation
Working hours per day
How did you hear about the clinic
Overall General Health
PHYSICIAN
CURRENT MEDICATIONS
SURGERIES
INJURIES/MOTOR VEHICLE ACCIDENTS
Primary Complaint
What is your primary complaint
PLEASE INDICATE CONDITIONS YOU ARE EXPERIENCING, OR HAVE EXPIRIENCED.
MUSCLES/JOINTS Pain/Stiffness
HEAD/NECK
RESPIRATORY
COMMUNICABLE DISEASES
FEMALE
CARDIOVASCULAR
OTHER CONDITIONS
OTHER HEALTH CARE
OTHER MEDICAL CONDITIONS: (e.g. digestive conditions, thyroid problems, nervous system, endocrine system, etc.)
OF SPECIAL NOTE: (presence of internal pins, wires, artificial joints, special equipment)

CANCELLATION POLICY: A cancellation service charge will apply if less than 48 hours notice has been given. The clinic will gladly assist you in understanding your insurance, but you agree that you are responsible for your account.

CONSENT TO TREATMENT
Patient Signature*
Clear
Name of Patient*
Date*
Chiropody Intake Form

Chiropody Intake Form

Date
Patient Name*
Date of Birth
Address
City/Town
Province
Postal Code
Email Address*
Phone*
Referred By
Family Doctor
Do you have any of the following?
Eye, Ear, Nose or Throat problems
Respiratory Problems
Heart Problems
Diabetes in the family
Kidney/Liver problems
Infectious diseases
Circulatory diseases
Bleeding diseases
Arthritis, osteoporosis, back, knee or leg pains
Skin diseases
Nerve disease
Any other diseases
Do you take medication (if yes, please list)
Do you have allergies
Have you had any operations
Have you broken any bones
Any other information I should be aware of?
What is your chief complaint

We will gladly assist you in understanding your insurance coverage, but you agree that you are responsible for your account.

I agree to Erin Mills Optimum Health collecting and using personal information about me as set out in their Privacy Policy, which I can review at this link.

Please note that a cancellation service charge will apply if less than 48 hours notice has been given.

  • FEE
  • Initial Assessment: $80.00
  • Subsequent Visit: $55.00
  • X-Rays (if necessary): $100.00
  • Custom Orthotics (if necessary): $550.00

I have read the above and consent to care at Erin Mills Optimum Health.

Date*
Patient Name*
Patient Signature*
Clear
Chiropractic & Wellness Clinic Mississauga
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