First name
*
Last name
*
E-mail
*
Home Phone
*
Cell Phone
*
Which service would you like to book an appointment for?
Choose service
*
Please Select
Chiropractic Care - Dr. Nathalie Beauchamp
Low-Level Laser Therapy
PEMF Therapy (pulsed electromagnetic frequency)
Registered Holistic Nutrition
Gait Scan Analysis - Customized Orthotics Fitting
Functional and Nutrition Lifestyle Coaching
Registered Massage Therapy (not currently taking new patients)
Referral Source:
*
Patient of the Clinic
Google Search/Website
Social Media
Other Health Professionals
If applicable, name of the person who referred you?
Do your currently fall under any of these categories:
Workplace Injury (WSIB) (Active Claim)
Motar Vehicle Accident (MVA)
RCMP
DND
Veteran (VAC)
Other specific requests or questions?
Submit
Should be Empty: