New Client Form - Natural Health/Nutrition Advice

New Client Form

Please complete this form prior to attending your initial consultation. Many thanks.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Post Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Date of Birth

DayMonthYear
Date
Emergency Contact - name and phone number*
Please include name, relationship and phone number
Please provide an overview of your current situation and medical status.
If the questions below do not apply to you, please type N/A.
Allergies & Intolerances*
Please provide an overview of what allergies and/or intolerances you may have.
Current Medications & Supplements*
Please provide an overview of what mediation and supplements you are currently taking, including the dose, frequency and how long you have been using it, plus any side effects from the medication.
Are you pregnant?*

YesNo
Previous medical diagnoses*
For example, diabetes, IBS, transplant, etc.
Previous surgeries*
Please provide an overview of any surgery within the last 12 months, or any surgery you are still suffering side effects from.
Tests & Scans*
Please provide an overview of tests or scans that you have had, in the last 12 months (or longer for a major surgery). If you have copies, please attach below, or bring to your appointment with you.
File Upload

Please upload your test/scan results if available
Cancelof
Occupation*
Please tell me what you do for work - this will help me get an idea of what toxins/injuries you may be exposed to.
Regular Hobbies*
Please tell me what you do for relaxtion - this will help me get an idea of what toxins/injuries you may be exposed to.
Disclaimer*

All information provided to Be Well Naturally will be held in the strictest confidence. Your written consent will be gained should we need to declare information to a 3rd party, for example, your GP. Also, I understand that Be Well Naturally can breach patient confidentiality to protect a client's safety or safety of others, for example, suicidal thoughts or intent to harm others.
Newsletter*

Please sign me up for your monthly newsletterI do not want to receive your monthly newsletter, thank you
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