Be sure to complete all steps with as much info as you can.

If you are unsure please call or email us.

  • Please complete the following Patient File

General Info

Name

Surname

Email

Phone Number - Mobile

ID Number

Date of Birth

Full Address

How did you hear about us?

Habits

Alcohol Drinks Per Week

Smoker/Vaper

THC User?

Narcotics User?

Chronic Medication User?

Consult

Is the consult for you?

If above No then for whom?

Why/What would you like to Heal?

Current Medications

Name / Description / Dosage / Used for. - IF None write none

Current Supplements

Name / Description / Dosage / Used for. - IF None write none

Known Conditions / Past Surgery

Please describe all details reharding previous conditions and or Surgery

Emergency Contact

Name

Relationship to you

Mobile Number

Concent

Do you accept we are not doctors and we do not offer more than herbal and natural healing advice and services.