Naturopath Intake Form

General Health Questionnaire

Below are a series of health symptoms. Please check boxes with a tick for present symptoms. Please leave the box blank if you have never experienced this symptom.

When performed by a qualified practitioner each and every therapy available to you in this pharmacy is an effective and safe treatment for many of the cases of pain and illness. There are however, risks associated with any treatment.

Adverse events are extremely rare but it is important for you to be informed of the risks, however low they may be.

I understand, and am informed that, as in the practice of medicine in the practice of Naturopathy there are some risks to the treatment. Possible adverse reactions include headache, fatigue, nausea and itchy skin, however these are rare.

I do not expect the practitioner to be able to anticipate and explain all the risks and complications, and I wish to rely on the practitioner to exercise judgement during the course of the treatment, which the practitioner feels at the time, based on the facts then known, is in my best interest.

I agree that the best way to reduce the chance of an unwanted effect is to answer all the documented questions about my health fully and honestly.

To secure your appointment a pre-payment is required prior to the appointment time. Pease note that this ensures your booking is confirmed. If you need to cancel or reschedule, we kindly ask for 48 hours notice. Cancellations made less than 24 hours before the appointment will incur a 50% fee of the total amount paid. We appreciate your understanding.

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