New Patient Intake Form

New Patient Intake Form

(if you're a returning client, just close this window now)

If you're new to nourishe please fill in as much detail as you can.

All information provided will assist with your consult, wellness plan, and any subsequent recommendations from me.

All details remain confidential.

ALL consults require a deposit to secure your booking.

If you're using a voucher you will need to enter your Voucher number as follows:
V followed by your voucher number eg V12345.
If this doesn't work (some older vouchers may not be entered in the system) please email me.

I'm looking forward to meeting you soon!

email Deborah here
Todays Date

DayMonthYear
Date
Name*

First NameLast Name
email*
Date of Birth*

DayMonthYear
Date of Birth*

DayMonthYear
Date
Contact Phone number (cellphone or landline):*

Area CodePhone Number
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Occupation*
How did you hear about nourishe?*
I'd like to send you an email occasionally, and I need your ok to do so!*

No - thanks anyway.Sure - I'd love to hear from you!
Please Choose either CONSULT or LIVE BLOOD SCREENING*

CONSULTLIVE BLOOD SCREENING

LIVE BLOOD SCREENING

Please answer the following questions to the best of your ability.
Within the last 3months have you (please tick any that apply):

Had Surgery (either local or general anaesthetic) ?Had a Serious Illness ?Pregnant or recent Pregnancy ?Other
Please elaborate on any of the above:
(optional)
Please list any supplements (self-prescribed or other) you are currently taking. Also details of an Prescription (or other) Medication you are currently on.:
(optional)
What is your MAIN reason for booking a LIve Blood Screening?:*
(optional)
DISCLAIMER:

Live Blood Screening is NOT a Diagnostic Tool.

Your screening will show what your Red Blood Cells look like, and I will make observations based on their size, shape & activity on screen.

I cannot and will not diagnose any medical condition, nor will I use this as a basis for any treatment options.

I will use any images &/or video taken at the time of your screening to make any relevant lifestyle and nutritional that I feel may help your general health & wellbeing.
Informed Consent:

I understand that I will be fully informed about my treatment and any possible side-effects, 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.

By submitting this form you agree to the above statement.
I have read & agree with the above INFORMED CONSENT.
First Name* Last Name*

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

Payment is required to secure your booking. *

CONSULT deposit only$112.50NZD

nourishe health & wellness now requires a deposit to secure your appointment. This is deposit is non-refundable. Should you need to reschedule, please give a minimum of 48 hours notice.

Live Blood Screening (pay in full only)$145.00NZD

Please note this is a non-refundable payment. You can reschedule with a minimum of 48 hours notice at no additional charge.

Enter coupon

Total $0.00NZD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

	Supplement (vitamin/mineral etc)	Brand	Dose taking	When started taking (date/year)	Reason for this supplement
Supplement type (eg B vitamin)
Supplement type (eg B vitamin)
Supplement type (eg B vitamin)
Supplement type (eg B vitamin)

	NO	YES
Antibiotics/Antifungals
Antidepressants
Anti-Diabetics / Insulin
Antihistamines
Anti-inflammatories / Aspirin
Antipsychotics
Antiulcer medications, antacids
Asthma Medications / inhalers
Chemotherapy
Heart
High blood pressure / Blood thinners
Hormones/Oral contraceptives
Paracetamol / Ibuprofen
Relaxants/Sleeping tablets
Steroids (e.g. cortisone)
Thyroid

	Prescription?	Over The Counter?	Dose taking	When started taking
Name of medication
Name of medication
Name of medication
Name of medication

CONSULT

LIVE BLOOD SCREENING