• Sally Broadhurst Naturopathic Intake Form

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  • Health Information

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  • Allergies and Sensitivities 

  • Supplements and Medications

  • Medical History 

  • Family History

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  • Naturopathic Consultation Informed Consent:

  • I understand and acknowledge the following:

    Nature of Naturopathic Treatment:

    • Naturopathic medicine uses natural therapies including herbal medicine, nutritional supplementation, dietary and lifestyle advice to support health and wellbeing
    • My naturopath is registered with the Australian Natural Therapists Association (ANTA) and maintains professional indemnity insurance
    • Naturopathic treatment is complementary to, not a replacement for, conventional medical care

    Potential Interactions and Risks:

    • Herbal medicines and nutritional supplements may interact with prescribed medications, potentially causing adverse reactions or altering the effectiveness of those medications
    • It is my responsibility to inform my naturopath of ALL medications, supplements, and treatments I am currently taking or receiving
    • I agree to inform my treating doctor(s) of any herbal medicines, supplements, or treatments prescribed by my naturopath
    • I will not alter, reduce, or cease any prescribed medications without first consulting the prescribing medical practitioner

    My Responsibilities as a Client:

    I agree to provide accurate and complete information about:

    • My current and past health conditions
    • All medications and supplements I am taking
    • Any known allergies or adverse reactions
    • Pregnancy status, suspected pregnancy, or breastfeeding
    • Any changes to my health status during the course of treatment

    Practitioner's Role and Scope:

    • My naturopath will provide complementary healthcare advice and treatment within their scope of practice and based on the information I provide
    • Treatment recommendations are made in good faith based on current evidence and professional training
    • My naturopath may refer me to other healthcare practitioners when appropriate
    • A confidential health record will be maintained in accordance with Australian privacy legislation
    • Privacy and Records:
      My health information will not be released to third parties without my written consent, except where required by law
      I have the right to access my health records upon request

    Cancellation and Rescheduling Policy:

    • If you need to cancel or reschedule, please give me at least 24 hours notice for a full refund or to reschedule. Cancellations with less than 24 hours notice will forfeit the session fee.

    Consent:
    I confirm that I have read, understood, and agree to the above terms. I have had the opportunity to ask questions and consent to naturopathic consultation and treatment.

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