initial consultation form dwca

1
Level 1 75 Willoughby Road, Crows Nest, NSW, 2065 Phone: 02 8095 8255 www.classicalacupuncture.com.au Initial Consultation Form: All information is strictly confidential Name: ________________________________________D.O.B _________ Address: _____________________________________________________ _____________________________________________________________ Phone: Home / Business:___________________Mobile:________________ Email:__________________________Occupation:____________________ Health Fund:____________________________Referral:________________ Medical History: Previous Surgery:_______________________________________________ Previous and / or Current Major Illness:_____________________________ _____________________________________________________________ Are you pregnant or trying to conceive? Yes No Current Medications and / or supplements: __________________________ _____________________________________________________________ Main Reason for visit: ___________________________________________ Do you understand and agree that any missed appointments will be charged at the full rate and that any cancellations within 24 hours will incur a charge of 50% of the scheduled appointment fee? Yes No Signed: ______________________________ Date: ___________________

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Page 1: Initial consultation form dwca

             

Level 1 75 Willoughby Road, Crows Nest, NSW, 2065 Phone: 02 8095 8255 www.classicalacupuncture.com.au

Initial Consultation Form:

All information is strictly confidential

Name: ________________________________________D.O.B _________

Address: _____________________________________________________

_____________________________________________________________

Phone: Home / Business:___________________Mobile:________________

Email:__________________________Occupation:____________________

Health Fund:____________________________Referral:________________

Medical History:

Previous Surgery:_______________________________________________

Previous and / or Current Major Illness:_____________________________

_____________________________________________________________

Are you pregnant or trying to conceive? Yes No

Current Medications and / or supplements: __________________________

_____________________________________________________________

Main Reason for visit: ___________________________________________

Do you understand and agree that any missed appointments will be

charged at the full rate and that any cancellations within 24 hours will incur

a charge of 50% of the scheduled appointment fee? Yes No

Signed: ______________________________ Date: ___________________