Contact Us!

Unionville Holistic Health Centre

Address:
317 Renfrew Drive, Suite 102
Markham,
Ontario,
Canada L3R 9S8
Phone: (905) 305-8260
Email: hdkapitan@gmail.com

Contact Form

Title:
*Name:
Date of Birth:
Address:
City:
Province/State:
Postal/ZIP Code:
Country:
Telephone:
Daytime -
Evening -
* E-mail:
Name of Family Doctor:
Telephone:
Referred By:
Please describe your illness:
Illness began as a result of:(according to you)
Are You On Prescription Drugs?
If YES, name of medication:
Have you had any surgery:
If YES, for what reasons?
Waiver:
I hereby confirm that I have sought of my own free will to the Holistic health services of HUMESH KAPITAN. I fully realize that he is not a licensed medical doctor nor claims to be. I understand that the health services provided are for my own lifestyle guidance, nutritional health, education and or relaxation. Whatever council, care and/or treatments I receive are solely suggestions and are in no way prescribing, diagnosing or claiming to cure or treat specific illness. I take full responsibility for any part of his advice, and / or treatment I wish to participate in, from this day forward. I have read the Waiver and agree to the terms: