Dr. Jane Reside, ND
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INTAKE  & INFORMATION FORMS

PREPARING FOR YOUR APPOINTMENT

Health intake forms for a naturopathic visit are notoriously long!  For that reason, I get you to fill it out ahead of time.  If you have access to a printer, please print the appropriate form,  fill it in, and bring it with you to your first appointment.  If you would like me to snail-mail you a form, please contact me with your mailing address, and provide at least one week for it to get to you.

​If you happen to have copies of your latest blood work or other lab diagnostics you've had done, those are always handy for me to see.  If not, we will discuss getting access to those during our first visit.  Or, if you'd like to get a jump start on that, you can fill out the Consent for Medical Records form, and bring that along with your health intake form to your first visit.

Confidentiality:  All patients are assured full confidentiality, meaning that all information shared with Dr. Reside  is private and kept secure on the premises.  Dr. Reside will not disclose any of your information to a third party without your prior, written consent, unless mandated by law, or if there is reason to believe you will be imminently harmed or in danger of harming yourself.
​FORMS
General Intake Form  - Adult (13 years old and up)

Prenatal Intake Form

​Infant & Child Intake Form  (up to 12 years old)

​Diet Diary
Consent for Medical Records

General Consent Form

Consent to Treatment of a Minor
LOCATION
G1 - 1284 Gladstone Ave
Victoria, BC V8T 1G6
P:  250-590-7015
F:  250-590-7016
E:  jane@drjane.ca

Appointments & Fees
HOURS (By appointment)
*Temporarily changed:

Tuesdays 9:30 - 5:30

​Thursdays 9:30 - 5:30


Get in Touch
  • Home
  • COVID-19: UPDATES TO PROTOCOLS & PROCEDURES
  • About
    • Naturopathic Medicine
  • Health Conditions
  • Treatments & Services
  • Appointments & Fees
    • Forms
  • Contact
  • Policy statements