Booking-Questions

NEW PATIENT INTAKE FORM

CAROLINE ROBERTSON
Dip Nat, Dip Nut, Dip RM, Dip Hom, Dip Bot. Med, Cert. Ayurveda
ATMS: 6703 E: info@carolinerobertson.com.au P: +61430092601

Booking FORM

Full Name *

First

Last

Phone number *

Emergency Contact *

Contact's relationship to you *

Email *

Date of birth *

Home address *

Postal address *

Children *

Occupation *

Current work status *

Weekly working hours *

Prior and current health conditions *

Which healthcare practitioners have you seen in the past for these conditions? *

What treatments are you currently receiving? *

Please list any medications/ supplements you are currently taking *

What are you consulting Caroline Robertson about today? *

Please list any surgeries and dates *

Alcohol - Frequency, types and quantity *

Smoking - Frequency, type and quantity *

Recreational drugs - Frequency, type and quantity *

If applicable and give details: Allergies/anaphylaxis / Breastfeeding / Contagious conditions / Covid symptoms / Hepatitis / HIV / Operations / Pregnant / Skin conditions / Previous dislocations, fractures, sprains *

Recreational drug use - Frequency, type and quantity *

Family health history *

Please attach relevant tests (ie. Blood work, investigations) *

Max file size: 20MB

Please attach relevant tests (ie. Blood work, investigations) *

Max file size: 20MB

Picture of the top surface of your tongue taken in good light and in focus *

Max file size: 20MB

Consent: I confirm that the above information I have provided is true, complete and accurate. I understand I have the right to refuse any procedure or treatment. I understand I have the right to discuss all medical treatments with my clinician. I do not expect the practitioner to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the practitioner to exercise judgment during the course of treatment which the practitioner thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand that natural therapy treatment is not intended to replace orthodox medical care or medical prescriptions. I understand that all information given in the written and or verbal form to Caroline Robertson is strictly private and confidential. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. I consent to receiving health advice and treatment from Caroline Robertson. PLEASE PRINT YOUR NAME: *

Parent or Guardian Signature and Date (for children under 18) - PLEASE PRINT YOUR NAME *

Comment *

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NEW PATIENT INTAKE FORM

Booking FORM

0430092601

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