Client’s Form

Your name

Address

City

Province

Postal / Zip Code

Phone

Email

Date of Birth

How did you hear about us?

What is your main concern that you want to address?

Describe any previous hormone or steroid treatments

Are you experiencing symptoms of hormone decline or ageing?
YesNo

If so, describe symptoms

List any medications and dosage that you are currently taking. Including non-prescription medications and/or hormone treatments

Do you smoke tobacco?
YesNo

Do you drink alcohol?
YesNo

Today's date

I hereby state that the above information is correct.

Waterloo Anti Aging is a private wellness clinic. All treatments and medications offered by Waterloo Anti Aging are not covered by provincial or private health insurance. All products or services are paid out of pocket.