New Patient Form

  • To help provide you with the most appropriate treatment options, please take time to answer the following questions. Only information will be gathered appropriate to ascertaining potential treatment options and will be completely confidential as per the Privacy Act 1988. As a member of the following professional organisations: Australian Natural Therapies Association (ANTA) and the Nutrition Society of Australia (NSA) I am bound by professional codes of conduct to protect both patient and practitioner.
  • Personal Details

  • Contact In Case of Emergency

  • Medical History

  • I understand the following:
    • I am over 18 years (inclusive) and have the ability to make my own decisions, if not I have my guardians / carers consent;
    • I am not being forced into a consultation and attendance is my own decision;
    • Any therapeutic strategies will be explained;
    • It is solely my decision to participate in any suggested treatment strategies which must be done under the guidance of Liz Mountford of Food & Nutritional Therapies; and
    • I have and will to the best of my knowledge supply correct and relevant information pertaining to this particular consultation.
 

Verification is used to ensure you are a real person and not spam.