Please fill & submit this form prior to your appointment adding as much information as possible to utilize this service to its full potential.
Thank you!
Do you have an Energy Slump during the day/evening?*
How often do you feel irritable/frustrated?*
How often do you feel apathetic/lethargic/depressed?
How often do you experience racing thoughts, dwelling on a situation or expressing compulsive behavior?*
Do you experience excess bloating/gas/burping?*
What aspects have improved from your last appointment? Tick all that is applicable.*
What aspects do you want more improvement in? Tick all that is applicable.*
Add any recent blood tests if relevant
It's important for us to collect your personal information before any consultation with you, so we can provide the best service at our practice.
Your personal information will be held confidentially in electronic record and in a manner that reasonably protects it from misuse and loss and from unauthorised access, modification or disclosure. Personal information will only be used for medical services and for payments, otherwise we will consult you for your consent.
Your personal information will not be disclosed with any third party without full disclosure with you. We will explain the reason beforehand, and will only share it with your consent.
There are some exceptions to disclose without your consent and that includes where we are required or authorised by law; this may include to prevent a serious threat to a patient's life or safety or to someone else's life, or if we are unable or it is impractical to obtain the patient's consent.
We will not use your personal information in any direct marketing without your consent. Appointment confirmations are not considered marketing communications.
Do you accept this policy?*
