NEW PATIENT INTAKE FORM
CAROLINE ROBERTSON
Dip Nat, Dip Nut, Dip RM, Dip Hom, Dip Bot. Med, Cert. Ayurveda
ATMS: 6703 ABN: 33265866770
6 Oceania Crescent Newport NSW 2106
E: [email protected] P: 0430 092 601

• First and middle names
• Surname
• Date of birth 
• Email Address 
• Mobile phone 
• Home address 
• Postal address 
• Children 
• Emergency Contact 
• Contact's relationship to you 
• Current work status 
• Occupation 
• 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)

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.
Signature:
Date: 
Parent or Guardian Signature and Date (for children under 18) ...................................………………………………
​

Booking option 1

Message

Send a message "I want a consultation with Caroline" to +61430092601

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Booking option 2

First and middle names
Surname
Date of birth 
Email Address 
Mobile phone 
Home address 
Postal address 
Children 
Emergency Contact 
Contact's relationship to you 
Current work status 
Occupation 
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)

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.
Parent or Guardian Signature and Date (for children under 18) ...................................………………………………
​