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
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.
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