New Client Information Form

New Client Information Form
Client Full Name*

First NameLast Name
Date Of Birth*

MonthDayYear
Date
What is your gender?*

MaleFemale
Legal Guardian Full Name (if under 16yrs old)

First NameLast Name
Relationship
Phone Number*
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Did your doctor / Biomed doctor refer you?*

YesNo
Referring doctor / Biomed Doctor's Name

First NameLast Name
Referring doctor / Biomed Doctor's email address:
example@example.com
Are you currently taking any medication?*

YesNo
List the medications*
Are you currently taking any natural Supplements?*

YesNo
List any natural Supplements*
Do you have any allergies or intolerances?*

YesNoNot Sure
What allergies or intolerances are you aware of?*
Have you or your child conducted any testing or treatment strategies previously or are you currently?*

YesNoNot Sure
What are those testing / treatment strategies?*
Check any conditions that may apply *

ASD/ Developmental delaysADHDAutoimmuneIBSSIBOParasitesSeizuresAsthmaCancerOther
What other conditions may apply?*
Main areas of Concern/ presenting complaints*
Have you travelled overseas recently?*

YesNo
Where have you travelled?*
Where did you hear about us?

Word of mouthFacebookInstagramEmailWeb searchOther social mediaReferred by professional
The Australian Centre for Genomic Analysis is always looking to improve the lives of children and adults with Autism, ADHD and other developmental delays along with gut issues and chronic illness though furthering research in these areas.

We would like your permission to use completely de-identifed data for research purposes.

To clarify you/your child will not be identifiable from this data in any way, it is simply the testing data itself that we are asking for permission to use.
Do you give permission for us to use this de-identified data.*

YesNo
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