We want to acknowledge your courage and willingness in reaching out for help. By answering the questions in this form as fully as you can you’ve taken an important step towards getting that help! When you get to the bottom of each page, click NEXT until you reach the end. You will be asked to sign before you can submit. Thank you!
** Allow about 15-20 minutes
** Make sure to finish in one sitting, and SUBMIT at the end, or your info may be lost.
Please fill in all of the information below with as much detail as you can and to the best of your ability so that you may recieve the best care possible! When you get to the bottom of each page, click NEXT until you reach the end. You will be asked to sign before you can submit. Thank you! P.S. Please visit this page to make sure you have completed all the steps necessary before your first visit with us!
* This information will be kept strictly confidential as per the Health Professions Act, Personal Information Protection Act, the requlations of each of the professional governing bodies for the professionals practicing at Numinus 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.
To provide you with the best possible care, professionals practicing out of Numinus share an Electronic Medical Record (EMR) system. All Practitioners and staff are bound by a Privacy & Confidentiality Agreement to protect your privacy. Practitioners must also fully comply with the privacy regulations of their professional colleges and designations and the privacy regulations of British Columbia and Canada.