EDIBLE PRESCRIPTION intake Form

EDIBLE PRESCRIPTION intake Form

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Adult Functional Health Intake Form
  • EDIBLE PRESCRIPTION Intake Form

  • Please fill in all of the information to the best of your ability. Thank you!

    * This information will be kept strictly confidential as per the Health Professions Act, Personl Information Protection Act, the requlations of each of the professional governing bodies for the professionals at Empower Health and Canadian law.  Your personal information is collected for the purpose of providing health care and for administrative purposes.  It will not be disclosed for other purposes without your consent other than for reasons stated in the laws.

  • Demographic Info

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