Butterfly Naturopathic Outreach Patient Application Form

    Date of Birth

    Patient Outreach Clinic Agreement

    Eligibility & Renewal
    Outreach clinic patients are approved based on an eligibility criteria presented in the Application Form, in addition to the availability of spots in the current schedule. Availability of spots will vary based on the number of Naturopathic Doctors involved in the Outreach clinic program.

    Once a patient is approved for the Butterfly Outreach Clinic Program, they will have access to treatments at a specific rate for a certain time frame, as determined by the program. Outreach renewal is not automatic.  Periodically, patients will be asked to re-apply and sign agreement forms if they desire continued care. Patient capacity is evaluated regularly throughout the year and patients may be discharged from the program as needed.  Please note that space is limited and not all patients will qualify for renewal. This will be based on a case-by-case basis to allow room for equal opportunity.

    Appointments (Outreach Clinic Hours are on Friday from 10am-2pm)
    Once patients are approved for the Outreach clinic, they will be sent a private link for online booking.  Appointment booking through the regular clinic’s online booking system is not applicable for Outreach clinic appointment rates but can be booked at regular rates.  If accidental bookings occur on the regular clinic schedule, patients will be expected to pay the full cost of the visit. Please note all Outreach clinic appointments must be prepaid upon booking.  

    Cancellation & No-Show Policy
    We require 24-hour notice in advance for all appointment cancellations. Appointments are paid in full in advance. Failure to comply with this policy will result in a non-refundable missed appointment fee. Repeated offenses may result in restricted access to appointment availability or a loss of placement in the Butterfly Outreach Clinic Program.  Patients that cancel with 24hrs notice can transfer their prepaid appointment to another time slot.
    Acknowledgement:
    I understand that:
    Outreach clinic renewal is not automatic and I may be asked to re-apply for continued care within the program. Patient capacity is evaluated regularly throughout the year.
    I will see whichever attending clinician is scheduled to me and they may not be the same clinician for each appointment.
    Appointments are available Friday from 10am to 2pm, must be prepaid, and will be coordinated by the booking software.  A  private link to a booking software  program will be provided if accepted to outreach program.  Booking for the outreach program can not be made through the Butterfly Naturopathic Website. 
    All communications for the Outreach clinic are via email only and communication via phone on Butterfly Naturopathic Clinic’s mainline is not available to Outreach patients in order to keep fees economical for the Outreach program patients.
    Max file size: 20MB
    Please upload your Notice of Assessment from last year.  There is a sample Notice of Assessment to the right.

    Please do not upload any other information other than your Notice of Assessment.
    In typing my name below I certify that I have read and understand the above terms and conditions for the Butterfly Outreach Clinic Program and the information provided in the Outreach Clinic Application Form is accurate and I have provided my Notice of Assessment for the previous year.