{"id":673,"date":"2017-12-08T17:35:30","date_gmt":"2017-12-08T17:35:30","guid":{"rendered":"http:\/\/docere.metronmarketing.ca\/?page_id=673"},"modified":"2025-02-12T04:09:57","modified_gmt":"2025-02-12T04:09:57","slug":"forms","status":"publish","type":"page","link":"https:\/\/docerewellness.com\/?page_id=673","title":{"rendered":"Forms"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; fullwidth=&#8221;on&#8221; _builder_version=&#8221;4.16&#8243; background_color=&#8221;#859324&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_fullwidth_header title=&#8221;Forms&#8221; text_orientation=&#8221;center&#8221; _builder_version=&#8221;4.16&#8243; background_color=&#8221;rgba(255, 255, 255, 0)&#8221; global_colors_info=&#8221;{}&#8221; button_one_text_size__hover_enabled=&#8221;off&#8221; button_two_text_size__hover_enabled=&#8221;off&#8221; button_one_text_color__hover_enabled=&#8221;off&#8221; button_two_text_color__hover_enabled=&#8221;off&#8221; button_one_border_width__hover_enabled=&#8221;off&#8221; button_two_border_width__hover_enabled=&#8221;off&#8221; button_one_border_color__hover_enabled=&#8221;off&#8221; button_two_border_color__hover_enabled=&#8221;off&#8221; button_one_border_radius__hover_enabled=&#8221;off&#8221; button_two_border_radius__hover_enabled=&#8221;off&#8221; button_one_letter_spacing__hover_enabled=&#8221;off&#8221; button_two_letter_spacing__hover_enabled=&#8221;off&#8221; button_one_bg_color__hover_enabled=&#8221;off&#8221; button_two_bg_color__hover_enabled=&#8221;off&#8221;][\/et_pb_fullwidth_header][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; disabled_on=&#8221;on|on|on&#8221; _builder_version=&#8221;4.16&#8243; disabled=&#8221;on&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row column_structure=&#8221;2_3,1_3&#8243; _builder_version=&#8221;4.16&#8243; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;2_3&#8243; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;|||&#8221; global_colors_info=&#8221;{}&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_blurb title=&#8221;Docere Wellness Downloadable Forms &#8221; use_icon=&#8221;on&#8221; font_icon=&#8221;&#x62;||divi||400&#8243; icon_color=&#8221;#7cda24&#8243; _builder_version=&#8221;4.20.2&#8243; use_circle=&#8221;off&#8221; use_circle_border=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p>The following forms apply to the following practitioners:<\/p>\n<p><strong>Dr. Rabia K. Meghji\u00a0<\/strong><\/p>\n<p>Please click on the form that relates to your upcoming appointment or doctor recommended treatment. The form will download onto your computer and you can fill it in and bring it with you when you come to the clinic. <a href=\"https:\/\/docerewellness.com\/wp-content\/uploads\/2018\/06\/Assignment-of-Benefits-Docere-Wellness.docx\">Click HERE<\/a> for the\u00a0Assignment of Benefits Form.<\/p>\n<p style=\"text-align: center;\"><a href=\"https:\/\/docerewellness.com\/wp-content\/uploads\/2018\/06\/PEDIATRICS-ChildIntakeQuestionnaire.doc\" target=\"_blank\" rel=\"noopener\">Pediatrics Child Intake Questionnaire<\/a><br \/><a href=\"https:\/\/docerewellness.com\/wp-content\/uploads\/2018\/06\/Adult-Naturopathic-Intake-Form.doc\" target=\"_blank\" rel=\"noopener\">Adult Naturopathic Intake Form<\/a><br \/><a href=\"https:\/\/docerewellness.com\/wp-content\/uploads\/2018\/06\/Consent-form.pdfhttps:\/\/docerewellness.com\/wp-content\/uploads\/2018\/06\/Consent-form.pdf\">Consent Form<\/a><br \/><a href=\"https:\/\/docerewellness.com\/wp-content\/uploads\/2018\/06\/Fertility-Intake-Form-Females.pdf\" target=\"_blank\" rel=\"noopener\">Fertility Program Females<\/a><br \/><a href=\"https:\/\/docerewellness.com\/wp-content\/uploads\/2018\/06\/Fertility-Intake-Form-Males.pdf\" target=\"_blank\" rel=\"noopener\">Fertility Program Males<\/a><br \/><a href=\"https:\/\/docerewellness.com\/wp-content\/uploads\/2018\/06\/TCM-Questionnaire.pdf\" target=\"_blank\" rel=\"noopener\">TCM Questionnaire<\/a><\/p>\n<p>[\/et_pb_blurb][\/et_pb_column][et_pb_column type=&#8221;1_3&#8243; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;|||&#8221; global_colors_info=&#8221;{}&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_code _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h1>Book Online Today<\/h1>\n<p><!-- [et_pb_line_break_holder] -->\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f1142-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"1142\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F673#wpcf7-f1142-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"1142\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.6\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1142-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"bookname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required et_pb_contact_name_1\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name\" value=\"\" type=\"text\" name=\"bookname\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"EmailAddress\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email et_pb_contact_email_1\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email Address\" value=\"\" type=\"email\" name=\"EmailAddress\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tel-556\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel et_pb_contact_email_1\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Phone Number\" value=\"\" type=\"tel\" name=\"tel-556\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"TreatmentofInterest\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required et_pb_contact_treatmentservices_1\" aria-required=\"true\" aria-invalid=\"false\" name=\"TreatmentofInterest\"><option value=\"-- Treatment of Interest* --\">-- Treatment of Interest* --<\/option><option value=\"Naturopathy\">Naturopathy<\/option><option value=\"Jump Start Packages\">Jump Start Packages<\/option><option value=\"CranioSacral\">CranioSacral<\/option><option value=\"Reiki\">Reiki<\/option><option value=\"Counselling\">Counselling<\/option><option value=\"NAET Treatment\">NAET Treatment<\/option><option value=\"Weight Loss\">Weight Loss<\/option><option value=\"Life Coaching\">Life Coaching<\/option><option value=\"Supplements\">Supplements<\/option><option value=\"General Information\">General Information<\/option><\/select><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Message\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea et_pb_contact_message_1\" aria-invalid=\"false\" placeholder=\"Message\" name=\"Message\"><\/textarea><\/span><br \/>\n[recaptcha]<br \/>\n<input class=\"wpcf7-form-control wpcf7-submit has-spinner et_pb_contact_submit et_pb_button\" type=\"submit\" value=\"Submit\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n[\/et_pb_code][et_pb_button button_url=&#8221;https:\/\/www.ratemds.com\/doctor-ratings\/77597\/Dr-Rabia-Meghji-Calgary-AB.html&#8221; 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background_color=&#8221;#b1c42d&#8221; result_message_font_size_tablet=&#8221;51&#8243; result_message_line_height_tablet=&#8221;2&#8243; border_style_all_fields_focus=&#8221;off&#8221; disabled=&#8221;on&#8221; global_module=&#8221;886&#8243; saved_tabs=&#8221;all&#8221; global_colors_info=&#8221;{}&#8221; button_text_size__hover_enabled=&#8221;off&#8221; button_one_text_size__hover_enabled=&#8221;off&#8221; button_two_text_size__hover_enabled=&#8221;off&#8221; button_text_color__hover_enabled=&#8221;off&#8221; button_one_text_color__hover_enabled=&#8221;off&#8221; button_two_text_color__hover_enabled=&#8221;off&#8221; button_border_width__hover_enabled=&#8221;off&#8221; button_one_border_width__hover_enabled=&#8221;off&#8221; button_two_border_width__hover_enabled=&#8221;off&#8221; button_border_color__hover_enabled=&#8221;off&#8221; button_one_border_color__hover_enabled=&#8221;off&#8221; button_two_border_color__hover_enabled=&#8221;off&#8221; button_border_radius__hover_enabled=&#8221;off&#8221; 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}<!-- [et_pb_line_break_holder] --> \/* Add your own MailChimp form style overrides in your site stylesheet or in this style block.<!-- [et_pb_line_break_holder] --> We recommend moving this block and the preceding CSS link to the HEAD of your HTML file. *\/<!-- [et_pb_line_break_holder] --><\/style>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div id=\"mc_embed_signup\"><!-- [et_pb_line_break_holder] --><\/p>\n<form action=\"https:\/\/docerewellness.us2.list-manage.com\/subscribe\/post?u=14aeb66a4d2f73a13289cda8d&#038;id=1eebb1ec9c\" method=\"post\" id=\"mc-embedded-subscribe-form\" name=\"mc-embedded-subscribe-form\" class=\"validate\" target=\"_blank\" novalidate><!-- [et_pb_line_break_holder] --> <\/p>\n<div id=\"mc_embed_signup_scroll\"><!-- [et_pb_line_break_holder] --> <\/p>\n<h2>Get the Latest Clinic Promotions <\/h2>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"indicates-required\"><span class=\"asterisk\">*<\/span> indicates required<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"mc-field-group\"><!-- [et_pb_line_break_holder] --> <label for=\"mce-EMAIL\">Email Address <span class=\"asterisk\">*<\/span><!-- [et_pb_line_break_holder] --><\/label><!-- [et_pb_line_break_holder] --> <input type=\"email\" value=\"\" name=\"EMAIL\" class=\"required email\" id=\"mce-EMAIL\"><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --> <\/p>\n<div id=\"mce-responses\" class=\"clear\"><!-- [et_pb_line_break_holder] --> <\/p>\n<div class=\"response\" id=\"mce-error-response\" style=\"display:none\"><\/div>\n<p><!-- [et_pb_line_break_holder] --> <\/p>\n<div class=\"response\" id=\"mce-success-response\" style=\"display:none\"><\/div>\n<p><!-- [et_pb_line_break_holder] --> <\/div>\n<p> <!-- real people should not fill this in and expect good things - do not remove this or risk form bot signups--><!-- [et_pb_line_break_holder] --> <\/p>\n<div style=\"position: absolute; left: -5000px;\" aria-hidden=\"true\"><input type=\"text\" name=\"b_14aeb66a4d2f73a13289cda8d_1eebb1ec9c\" tabindex=\"-1\" value=\"\"><\/div>\n<p><!-- [et_pb_line_break_holder] --> <\/p>\n<div class=\"clear\"><input type=\"submit\" value=\"Subscribe\" name=\"subscribe\" id=\"mc-embedded-subscribe\" class=\"button\"><\/div>\n<p><!-- [et_pb_line_break_holder] --> <\/div>\n<p><!-- [et_pb_line_break_holder] --><\/form>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><script type='text\/javascript' src='\/\/s3.amazonaws.com\/downloads.mailchimp.com\/js\/mc-validate.js'><\/script><script type='text\/javascript'>(function($) {window.fnames = new Array(); window.ftypes = new Array();fnames[0]='EMAIL';ftypes[0]='email';fnames[1]='FNAME';ftypes[1]='text';fnames[2]='LNAME';ftypes[2]='text';fnames[3]='MMERGE3';ftypes[3]='text';}(jQuery));var $mcj = jQuery.noConflict(true);<\/script><!-- [et_pb_line_break_holder] --><!--End mc_embed_signup-->[\/et_pb_code][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; 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Meghji\u00a0<\/strong><\/p>\n<p>Please click on the form that relates to your upcoming appointment or doctor recommended treatment. The form will download onto your computer and you can fill it in and bring it with you when you come to the clinic. <a href=\"https:\/\/docerewellness.com\/wp-content\/uploads\/2018\/06\/Assignment-of-Benefits-Docere-Wellness.docx\">Click HERE<\/a> for the\u00a0Assignment of Benefits Form.<\/p>\n<p>[\/et_pb_blurb][\/et_pb_column_inner][\/et_pb_row_inner][et_pb_row_inner column_structure=&#8221;1_3,1_3,1_3&#8243; admin_label=&#8221;Row&#8221; module_id=&#8221;my-buttons&#8221; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_column_inner type=&#8221;1_3&#8243; saved_specialty_column_type=&#8221;3_4&#8243; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;|||&#8221; global_colors_info=&#8221;{}&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_button button_url=&#8221;https:\/\/docerewellness.com\/wp-content\/uploads\/2018\/06\/PEDIATRICS-ChildIntakeQuestionnaire.doc&#8221; url_new_window=&#8221;on&#8221; button_text=&#8221;Pediatrics Child Intake Questionnaire&#8221; 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}<!-- [et_pb_line_break_holder] --> \/* Add your own MailChimp form style overrides in your site stylesheet or in this style block.<!-- [et_pb_line_break_holder] --> We recommend moving this block and the preceding CSS link to the HEAD of your HTML file. *\/<!-- [et_pb_line_break_holder] --><\/style>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div id=\"mc_embed_signup\"><!-- [et_pb_line_break_holder] --><\/p>\n<form action=\"https:\/\/docerewellness.us2.list-manage.com\/subscribe\/post?u=14aeb66a4d2f73a13289cda8d&#038;id=1eebb1ec9c\" method=\"post\" id=\"mc-embedded-subscribe-form\" name=\"mc-embedded-subscribe-form\" class=\"validate\" target=\"_blank\" novalidate><!-- [et_pb_line_break_holder] --> <\/p>\n<div id=\"mc_embed_signup_scroll\"><!-- [et_pb_line_break_holder] --> <\/p>\n<h2>Get the Latest Clinic Promotions <\/h2>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"indicates-required\"><span class=\"asterisk\">*<\/span> indicates required<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"mc-field-group\"><!-- [et_pb_line_break_holder] --> <label for=\"mce-EMAIL\">Email Address <span class=\"asterisk\">*<\/span><!-- [et_pb_line_break_holder] --><\/label><!-- [et_pb_line_break_holder] --> <input type=\"email\" value=\"\" name=\"EMAIL\" class=\"required email\" id=\"mce-EMAIL\"><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --> <\/p>\n<div id=\"mce-responses\" class=\"clear\"><!-- [et_pb_line_break_holder] --> <\/p>\n<div class=\"response\" id=\"mce-error-response\" style=\"display:none\"><\/div>\n<p><!-- [et_pb_line_break_holder] --> <\/p>\n<div class=\"response\" id=\"mce-success-response\" style=\"display:none\"><\/div>\n<p><!-- [et_pb_line_break_holder] --> <\/div>\n<p> <!-- real people should not fill this in and expect good things - do not remove this or risk form bot signups--><!-- [et_pb_line_break_holder] --> <\/p>\n<div style=\"position: absolute; left: -5000px;\" aria-hidden=\"true\"><input type=\"text\" name=\"b_14aeb66a4d2f73a13289cda8d_1eebb1ec9c\" tabindex=\"-1\" value=\"\"><\/div>\n<p><!-- [et_pb_line_break_holder] --> <\/p>\n<div class=\"clear\"><input type=\"submit\" value=\"Subscribe\" name=\"subscribe\" id=\"mc-embedded-subscribe\" class=\"button\"><\/div>\n<p><!-- [et_pb_line_break_holder] --> <\/div>\n<p><!-- [et_pb_line_break_holder] --><\/form>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><script type='text\/javascript' src='\/\/s3.amazonaws.com\/downloads.mailchimp.com\/js\/mc-validate.js'><\/script><script type='text\/javascript'>(function($) {window.fnames = new Array(); window.ftypes = new Array();fnames[0]='EMAIL';ftypes[0]='email';fnames[1]='FNAME';ftypes[1]='text';fnames[2]='LNAME';ftypes[2]='text';fnames[3]='MMERGE3';ftypes[3]='text';}(jQuery));var $mcj = jQuery.noConflict(true);<\/script><!-- [et_pb_line_break_holder] --><!--End mc_embed_signup-->[\/et_pb_code][\/et_pb_column][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;3.0.89&#8243; background_color=&#8221;#778420&#8243; background_image=&#8221;https:\/\/docerewellness.com\/wp-content\/uploads\/2017\/07\/landscape-922581_1920-1024&#215;723.png&#8221; background_position=&#8221;top_center&#8221; background_blend=&#8221;darken&#8221; custom_padding=&#8221;54px|0px|0px|0px&#8221; global_module=&#8221;698&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;|||&#8221; global_colors_info=&#8221;{}&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_text _builder_version=&#8221;4.16&#8243; background_layout=&#8221;dark&#8221; max_width=&#8221;60%&#8221; module_alignment=&#8221;center&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h1 style=\"text-align: center;\">Our Goals at Docere Wellness Centre are:<\/h1>\n<p style=\"text-align: center;\">&#8230; to listen and be respectful<br \/>&#8230; to create a collaborative partnership<br \/>&#8230; to treat the whole person, not the illness<br \/>&#8230; to address the root cause and not just treat symptoms<br \/>&#8230; to honour the healing power of nature<\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;3.0.89&#8243; background_color=&#8221;#b1c42d&#8221; background_size=&#8221;contain&#8221; background_blend=&#8221;darken&#8221; global_module=&#8221;706&#8243; global_colors_info=&#8221;{}&#8221;][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>The following forms apply to the following practitioners: Dr. Rabia K. Meghji\u00a0 Please click on the form that relates to your upcoming appointment or doctor recommended treatment. The form will download onto your computer and you can fill it in and bring it with you when you come to the clinic. Click HERE for the\u00a0Assignment [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":8317,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","footnotes":""},"class_list":["post-673","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.7 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Forms - Docere Wellness Centre<\/title>\n<meta name=\"description\" content=\"Looking for a natural healing to improve your health? Check out what Traditional Chinese Medicine Northwest Calgary has to offer. 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