Welcome to Integrative Health Clinic

Welcome to Integrative Health Clinic

This is the Integrative Health Clinic patient registration form. Once completed you will receive an email invitation to set up your Members Portal access where you can browse our full product range, view pricing, read the Members Guidebook and book your practitioner consultation.Already registered? Please visit our Members Portal and log in directly — no need to complete this form again.Members Portal →
Page 1 — Personal Details
Full Name

First NameMiddle NameLast Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Medicare Card Number
Your Medicare card number and IRN can be found through your MyGov account or on your physical Medicare card.
Medicare Card IRN Number
I confirm that the name, date of birth and Medicare number I have provided above are entered exactly as they appear on my Medicare card. I understand that if these details do not match the Medicare database, I may be required to provide my Individual Healthcare Identifier (IHI) number to ensure eScripting services can be completed.
IHI Number
If you know your Individual Healthcare Identifier (IHI) please enter it here. You can find this in your myGov or My Health Record account. This helps us process your prescription.
Gender
Email Address
example@example.com
Mobile Number
Mobile Number
Please enter a valid phone number.Format: 0000 000 000 .
Residential Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: 0000 000 000 .
Emergency Contact Relationship
How did you Hear about us?
Referred by a partner clinic or friend? Let us know!
Page 2 — Medical History
Current Medications — Please list all current medications including dose
Known Allergies — Please list any known allergies to medications, substances or other
Do you have any existing medical conditions?
Please describe your medical conditions
Have you had any previous surgeries or significant injuries?
Please describe
Current GP Name
Current GP Practice and Address
Do you smoke?
Alcohol consumption
Exercise frequency
Primary health and wellness goals — Please describe what you are hoping to achieve
Have you previously used compounded peptide products?
Please describe your previous experience
Is there anything else you would like your practitioner to know?
Page 3 — Consent & Signature
Please read each statement carefully and check each box to confirm your understanding and agreement before signing.
I acknowledge that all products offered through Integrative Health Clinic are prescription-only compounded medicines and require a valid practitioner prescription before being dispensed.
I acknowledge that compounded medicines are not TGA-registered products and are prepared specifically for me as an individual patient based on a valid prescription.
I consent to a practitioner consultation prior to any prescription being issued and understand that a consultation fee applies.
I confirm that all personal and medical information provided in this form is accurate and complete to the best of my knowledge. I understand that providing inaccurate information may affect the quality of care provided.
I consent to my personal and medical information being collected, stored and used by Integrative Health Clinic in accordance with the Australian Privacy Act 1988.
I confirm that I am 18 years of age or older.
I have read and agree to the Integrative Health Clinic Terms and Conditions
Electronic Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Welcome to Integrative Health Clinic

Page 1 — Personal Details

Page 2 — Medical History

Page 3 — Consent & Signature