Children's Natural
Medicine Form
(Age 12 and under)

Children are the loves of our lives.  We want the very best for our children, and at Conscious Body Natural Medicine they are more than special.  In order to help your child overcome symptoms and regain their bouncy selves, please take the time to fill out this form as completely as possible.   By clicking Submit at the end of this form, you are giving your consent for us to work with your child in your presence per your request.  Please make sure you complete the form and click submit before leaving this page, otherwise your information will not be saved and submitted.

Child's Name *
Child's Name
Address *
Mother's Name *
Mother's Name
Father's Name *
Father's Name
Contact Phone Number *
Contact Phone Number
Please provide a number where we can reach you at any time.
Child's Date of Birth *
Child's Date of Birth
Please include both over the counter medicines as well as prescriptions
Environmental, pet, food, topical?
Please check all conditions or symptoms that your child has EVER had: *
For Mommy: Please check the applicable items regarding your pregnancy and birth of this child's birth:
Lead paint, new carpets, household smoking, mildew or mold, pesticides or herbicides, air problems, etc.

By clicking Submit, I am providing all my child's information and voluntarily consent to have my child examined and evaluated, realizing that no guarantees have been given to me by the naturopathic physician regarding cure or improvement of my condition.  I understand that Karen Clickner will answer any questions to the best of her ability and I understand that treatment results are not guaranteed.  I do not expect her to be able to anticipate and explain all potential risks and complications of treatment. I understand that she  will use her best judgment throughout the course of the procedure and make decisions in a manner that she feels is in my child's best interests at the time based on the facts known. With this knowledge, I voluntarily consent to any diagnostic and therapeutic procedures provided for my child through Conscious Body Natural Medicine.  I understand that the record of health services provided is confidential.