BEAT DIABETES PROGRAM REGISTRATION FORM

Thank you for choosing our the BEAT DIABETES program. We look forward to partnering together on a journey to wholeness.

For details on the program, click here.

Please complete and submit the form below.  If you have any questions or require assistance, don't hesitate to contact us:
Email: 
info@pathwaystowholeness.ca
Text/Call: 647-853-3455

Thank you!


Name *
Name
Session date *
Sex *
Phone number
Phone number
Address *
Address
Medical Concern
In addition to type 2 diabetes, what other medical condition(s) do you have? *
Please write a history of the chief concern(s) including: when it started, current symptoms and treatments (including medications, supplements), what you hope to achieve through naturopathic care, and any other pertinent information you feel is necessary.
List all medications and supplements (if not listed above). Please include dosages if possible, and when you started taking.
Please share any other information you feel is necessary for us when considering your case