Please fill out the below forms prior to your appointment.
Sunflower Naturopathy Clinic
New Client Form
Name____________________________________
Address__________________________________
Phone Number____________________________
Current Health Issues_______________________
________________________________________
________________________________________
Have you ever been to an Naturopath?
________________________________________
By signing below you understand that Dr. Asencio
is a Traditional Naturopath, and not a medical doctor.
She can not and will not, treat, cure, or diagnose your
condition/ ailment. She is here to educate you on a
all natural approach to your condition.
Signature_________________________
Date_____________________________
Sunflower Wellness
Medical Questionaire
What are your current medical conditions?
__________________________________________________
__________________________________________________
__________________________________________________
What Medications are you currently taking?
__________________________________________________
__________________________________________________
___________________________________________________
What Goals do you have by seeing a Naturopath?
___________________________________________________
___________________________________________________
___________________________________________________
Sunflower Naturopathy Clinic
New Client Form
Name____________________________________
Address__________________________________
Phone Number____________________________
Current Health Issues_______________________
________________________________________
________________________________________
Have you ever been to an Naturopath?
________________________________________
By signing below you understand that Dr. Asencio
is a Traditional Naturopath, and not a medical doctor.
She can not and will not, treat, cure, or diagnose your
condition/ ailment. She is here to educate you on a
all natural approach to your condition.
Signature_________________________
Date_____________________________
Sunflower Wellness
Medical Questionaire
What are your current medical conditions?
__________________________________________________
__________________________________________________
__________________________________________________
What Medications are you currently taking?
__________________________________________________
__________________________________________________
___________________________________________________
What Goals do you have by seeing a Naturopath?
___________________________________________________
___________________________________________________
___________________________________________________