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Mount Helena, WA, 6082
0422 586 002
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Home
About
Consultations
Intake Form
Shop
Contact
CLIENT INTAKE FORM
Name
*
First Name
Last Name
Address
*
Phone
*
Email
*
Date of Birth
*
Occupation
Emergency Contact
*
Name and phone number
General Practitioner
Reason for coming
*
When did these symptoms start?
Other health concerns
Family Health History (heart disease, HBP, diabetes, stroke, cancer, mental illness... )
Do you smoke?
Are you pregnant/ breastfeeding?
Allergies and Intolerances
*
Current Medications (including contraceptives)
*
Reason for taking them, duration and dosage
Past Medications/ Vaccines
Current Supplements
Reason for taking them, duration and dosage
Referred by
Disclaimer
By ticking this box, I acknowledge that all information provided is accurate. I will advise my practitioner about any changes in the future. I understand that all medical details and information shared during consultations will be treated with confidentiality. As with any substances, allergic reactions, side effects and symptom aggravations are possible and cannot always be predicted. I authorise Sandra Bitunjac to treat my condition through the use of herbal remedies and I understand that the results are not always guaranteed. I am free to withdraw my consent and discontinue treatment at any time. I agree that all herbal remedies are taken at my own risk. I have carefully read this agreement and fully understand the content.
Thank you!
