Adult Intake Form


Welcome to George Street Naturopathic Medicine and congratulations for putting your health first. By investing in Naturopathic Medicine, you have taken a major step to improving your health now and for the future. As your Naturopathic Doctor, I am certain you will find your experience a positive and rewarding one.

In making your appointment you have demonstrated that you are intent and ready to make the shifts in your life that are necessary to experience total health. Please take the time to fill out the important questionnaire below. The responses you provide will greatly assist me to understand your health goals so that we can formulate an individualized health care plan tailored to your needs. Rest assured that all the information you share on these forms and in our interactions will be held with the utmost confidentiality.

At present, Naturopathic care is not covered by OHIP. However, if you have extended medical insurance, please check with your plan to see if there is “Naturopathic Coverage”, as many of the major insurance companies do offer this. At the end of each visit you will be provided with the appropriate receipts to submit to your insurance company.

I sincerely thank you for taking this step towards the betterment of your health and I look forward to seeing you at your visit to the clinic.

Dr. Joanna Thiessen, B.Sc., N.D.
George Street Naturopathic Medicine
51 George Street
Waterloo, ON 519.575.6016

Note – Please make sure you have filled out the Informed Consent – Click Here

Beginning January 1, 2004, the Canadian Federal Government's privacy legislation, the Personal Information Protection and Electronic Documents Act (the Act) came into force for private business. This office is committed to protecting your personal information in accordance with this Act.

In general, The Act requires that the office obtain your consent before obtaining or using information about you or disclosing this information to others (there are some exceptions). This requirement also applies to personal information that has already been collected about you before January 1, 2004.

This notice explains why the office collects personal information from you, how it will be used and the steps being taken to ensure your privacy is protected.

What is personal information?
Personal information is information that identifies you as an individual. It includes information such as your name, address, telephone number, e-mail address, and date of birth, medical history and medical records.

What happens to my personal information?
All information collected by this office, remains in this office. Files are placed in a locked cabinet and can only be accessed by Dr. Joanna Thiessen and her personal staff. All information contained in the practice including telephone conversations, correspondence and files are privileged information and cannot be released, copied or discussed without the prior written consent of the patient. Staff are aware of personal identifying information only. They pull and file records as required. I have read this notice and understand it contents.


51 George Street
Waterloo, ON
N2J 1K8

Phone: 519-575-6016
Fax: 226-444-6755

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