New Patient Registration Form

nourishe

New Patient Intake Form

Thanks for taking the time to complete this form. All information provided will assist with your consult and subsequent recommendations from me. All details remain confidential.

A deposit is required to secure your booking.

Todays Date

Date

Name *

First Name Last Name

email *

Date of Birth *

Day Month Year

cellphone:

Area Code Phone Number

landline:

Area Code Phone Number

Address: *

Street Address

Street Address Line 2

City

Postal / Zip Code Country

Occupation *

How did you hear about nourishe? *

Woluld you like to receive my monthly @nourishe newsletter? *

No Yes

Within the last 6-12 months have you had/done any of the following:

Overseas Travel Surgery Serious Illness Trauma or Injury Pregnant or recent Pregnancy Covid-19 (including been to a location of interest, been around a close contact of or with someone who tested positive for covid)

Current Medical or Complementary Treatment *

Please include Homeopathic, Herbal, Vitamins and any other treatment providers you are currently working with

NUTRITION - please tick any that apply *

Vegetarian Vegan Dairy Free Gluten Free Coeliac (medically diagnosed) FODMAPS Other Nothing in particular

If other please describe:

EXERCISE *

Highly active (exercise 5+ times per week) Moderately active (exercise 3-5 times per week) Less active (exercise less than 3 time sper week) Inactive

Please provide more details (type of exercise, time of day etc):

Are you concerned about a possible reaction to a covid vaccination &/or post covid symptoms? If so please list your specific concerns here:

What is/are your main reason for booking a consult? *

What is the outcome / result you want? *

Please add any other relevant info or concerns you may have

I gather as much information as possible from you in order to develop what I believe to be the best plan for your specific needs. Often this involves you committing to making changes over a period of time. How committed are you to putting in the effort required? *

100% on board & will do everything I can 85% - I'm willing to make some changes & go from there 50% - to be honest I'm overwhelmed & will struggle with change Making this appointment is the best I can do right now, I just need some help

Informed Consent:

I agree that I will be fully informed about my treatment and have all my questions answered to my satisfaction. I consent to a physical assessment (if needed) and treatment plan as explained to me by Deborah Wright (practitioner).

I understand that if I am unhappy with the treatment provided I can in the first instance address this with Deborah Wright (practitioner). Alternatively I can contact an independent Health and Disability Advocate by phoning (04) 494 7900.

I have read & agree with the above INFORMED CONSENT.
First Name* Last Name*