New Client Form

New CLient Form

Name(required)

Date of birth(required)

Email(required)

Phone Number(required)

Address(required)

Emergency Contact Person(required)

Emergency Contact Phone Number(required)

Height (cm)(required)

Weight (cm)(required)

Blood pressure (if known)

Pulse (if known)

Usual Occupation(required)

Do you have any allergies, sensitivities or intolerances?(required)

Current medications, vitamins and supplements (Please include brand names and dosages)(required)

Diagnosed medical conditions(required)

Past illnesses and operations(required)

Overview of what you would like to achieve with the consult(required)

As a patient, I hereby acknowledge that I am willing to provide my practitioner with the information necessary for them to fully understand my medical history, presenting symptoms, and the health goals I wish to achieve in our work together. I thereby consent to a thorough case history. I understand that a record of my personal health information and of the services provided to me will be kept. This record will be kept confidential and will not be released to others unless so directed by myself or unless required by law. I understand that naturopathic, nutritional and herbal medicine can be employed in conjunction with other forms of therapy and need not be considered exclusively beneficial. I acknowledge that one method of treatment need not be chosen over others and that various methods often work best in conjunction with one another. I recognise that even the gentlest forms of treatment potentially have their risks and complications. The risks associated with naturopathic, nutritional and herbal medicine include, but are not limited to, aggravation of pre-existing symptoms, allergic reactions to herbs or interactions with prescription medications. As with all forms of therapy, I understand that naturopathic, nutritional and herbal medicine also has its limitations and thus I understand that the results are not guaranteed. Nor do I expect my practitioner to be able to anticipate and explain all risks and complications prior to treatment. With this knowledge, I voluntarily consent to to treatment and I intend for this consent form to cover my entire course of treatment. I understand that I am free to withdraw my consent at any time. I understand and agree that the details of my case my be published as a case report, without any personally identifying information (names and locations are never published).(required)

I have read and agree to the Terms of Service (https://youngdistributor.com/terms-of-service)(required)