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Dr. Stephen Maltier ND, M.Sc. 88 Dover Mills Road Port Dover, ON. N0A 1N1 Office: 5195831234 Fax 5195831018 www.dovernaturopath.com PEDIATRIC INTAKE FORM (under 16 years of age)PLEASE NOTE: WE ARE
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Step 1: Open the intake form pediatric2021.docx document.
02
Step 2: Start by entering the patient's full name in the designated field.
03
Step 3: Fill in the patient's date of birth, gender, and contact information.
04
Step 4: Provide the names and contact information of the patient's parents or guardians, if applicable.
05
Step 5: Answer the medical history questions thoroughly, providing details about any previous illnesses, allergies, or surgeries.
06
Step 6: Indicate the patient's current medications, if any.
07
Step 7: Complete the family medical history section by providing details about any hereditary diseases or conditions that run in the family.
08
Step 8: If the patient has any specific medical concerns or conditions, describe them in the appropriate section.
09
Step 9: Sign and date the intake form to give consent for the provided information.
10
Step 10: Make sure all required fields are filled out before submitting the form.

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The intake form pediatric2021.docx is needed by any pediatric patient or their guardian who is seeking medical treatment or services.
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The intake form pediatric2021docx is a form used to gather information about pediatric patients for medical purposes.
Pediatric patients or their guardians are required to fill out and file the intake form pediatric2021docx.
The intake form pediatric2021docx can be filled out by providing accurate information about the pediatric patient's medical history, symptoms, and other relevant details.
The purpose of intake form pediatric2021docx is to collect essential information about the pediatric patient that can help healthcare professionals provide appropriate medical care.
Information such as patient's name, date of birth, medical history, allergies, current medications, and symptoms must be reported on intake form pediatric2021docx.
The penalty for late filing of intake form pediatric2021docx may vary depending on the healthcare facility or organization's policies.
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