CONSENT TO USE ELECTRONIC COMMUNICATIONS

Aimee Marples, DCHM, HD (RHom)

PATIENTS: Please complete each section of personal information on this page, initial the bottom of each page and any other required field noted thorough this document.

HOMEOPATH INFORMATION:

Name: Aimee Marples
Address: 155 Riverglen Drive, Keswick, ON, L4P 3M3 “Two Feathers Yoga”
Email (if applicable): aimeemarples@gmail.com
Phone (as required for Service(s)): 289-716-1152
Website (if applicable): www.aimeemarples.com

The Homeopath has offered to communicate using the following means of electronic communication (“the Services”):

Email ( Videoconferencing (including Skype®, FaceTime®)

Text messaging (including instant messaging)

Website/Portal

Social media (specify): Instagram + Facebook -- @lovehomeopathy

Other (specify):

Other:

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone: Home

(###)

###

####

Telephone: Mobile

(###)

###

####

Email

Other account information required to communicate via the Services (if applicable):

Patient Signature:

Date of Signature

MM

DD

YYYY

This document has been adapted for the use of registrants of the College of Homeopaths of Ontario with permission from the Canadian Medical Protective Association.