Patient Forms

Our forms are now online and easy to fill out!  They will be emailed directly to us upon completion. Thank you for choosing Eastern Therapies. We look forward to meeting you!

Please carefully choose the form that best suits your concerns and fill out one form only.

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General Health Form: for any physical, mental, or emotional conditions, such as chronic or acute illness, injury, or stress.  If you are coming for natural fertility, IVF, or are pregnant/ have pregnancy-related concerns, please do not use this form and choose one of the other forms below.
Confidential New Patient Intake Form: General Health

Pregnancy Form:  for current pregnancy related conditions or labour preparation treatment.
Confidential New Patient Intake Form: Pregnancy

Female Natural Fertility Form: for natural conception assistance.
Confidential New Patient Intake Form: Female Natural Fertility

Female IVF or IUI Form: assisted conception patients
Confidential New Patient Intake Form: Female IVF or IUI

Male Fertility Form: for natural or IVF/IUI
Confidential New Patient Intake Form: Male Fertility

Pediatrics Form: for children 0-12 years of age
Confidential New Patient Intake Form: Pediatric General Health Age 0-12 years

Facial Rejuvenation Form: Confidential New Patient Intake Form: Facial Rejuvenation

Post Birth Questionnaire: If you have recently given birth after coming to us for labour preparation treatments, we would like to know more about your birth experience! Please fill out this brief survey to help us to better assist our pregnant clients.
Post Birth Questionnaire

Quick Form, Office Use Only: Confidential New Patient Form

Goals for Your Health – New patients: Goals for Your Health

Goals for Your Health – Returning patients: Goals for Your Health – Returning Patients