All new patients must complete the form below:

New Patient Questionnaire

First Name

Last Name

Age

Date Of Birth

Main reason for contacting me today

Address

City

Postcode

Country

Phone Number

Can we email you about offers, information and tips?

Yes

Occupation

Hours per week

Nature of Complaint(s)

Medical History

Medications

Supplements

How did you learn about the clinic?

Emergency contact name & phone number

GP/Specialist

In consideration of the treatment I receive, I hereby agree to indemnity, release forever discharge the said practitioner from all actions, sults, claims and demands relating to or arising from the treatment I receive, including all claims or demands which may be brought against me by any third party, and I do further agree that this indemnity may be pleaded in complete bar to any proceedings instituted by me and I specially indemnify the said practitioner in respect of any liability or claims by any third party, which may arise as the result of the use or application of the said treatment I so receive

I agree

E-Signature 'I digitally sign this agreement and agree to the Terms & Conditions.' TYPE NAME

New Patient Questionnaire

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