Patient Intake Form

Please help me to provide you with the most appropriate treatment possible by taking the time to complete this information questionnaire carefully and completely. Any information provided will be treated with complete confidentiality as per Australian National Privacy Principles and not used for any other purpose.

It is a legal obligation for the practitioner to capture this information prior to commencement.

Name

First Name

Last Name

Phone

(###)

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Email

Subject

Address

PO.Box not accepted.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name

Emergency Contact Phone

(###)

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Referred By:

Please list any known allergies:

List any medications/supplements currently taking:

Patient Consent

Please read and tick the consent box below after reading the following: Naturopathic medicine focuses on the treatment and prevention of diseases by assessing the whole person. This takes into account the physical, mental, and emotional aspects of the patient. A number of different methods are used. These include, but are not limited to: Nutritional advice, Prescription of Herbal medicine, Pathology Testing: In or out of clinic, Physical and exercise recommendations, Referrals to other practitioners where needed, Lifestyle counselling, Life and Mindset Coaching. There are some health risks with treatment from Naturopathic Medicine that may occur on rare occasions. These include, but are not limited to: Aggravation of pre-existing symptoms and conditions, allergic or hypersensitive reactions to herbs and or supplements, side effects due to some forms of treatment, including but not limited to herbal medicines or supplements. I request and consent to Bianca Maricchiolo to treat myself as Bianca Maricchiolo sees fit, and I have discussed or have had the opportunity to discuss with my practitioner, Bianca Maricchiolo, the nature and purpose of my naturopathic care and I consent to this care offered to me. I do not expect my practitioner to be able to anticipate and explain all risks and complications and I rely on them to exercise good judgement during the carrying out of her /their care. I authorise Bianca Maricchiolo Naturopath to treat my condition through the use of Naturopathic methods and I understand that the results of this approach are not guaranteed. I have read the above and consent. I have had the opportunity to ask questions about its content to my satisfaction. I understand that I am free to withdraw my consent and discontinue participation in these procedures at any time. I have read and agree to the above.

Yes

Terms of Service.

I agree to treat each patient to the best of my ability and always put the patients needs first. However, please be aware that healing takes time and sometimes it takes time to work out what is causing the health issues. This takes commitment from not only the practitioner but also the patient. Healing may have ups and downs on the journey towards recovery and this is normal. It is important to continue treatment and to commit towards following the treatment protocol if a successful outcome is to occur. Treatment may involve a range of diet and lifestyle medications, along with herbal medicines and nutritional supplements. The natural medicines / supplements used by this practitioner can only be prescribed by a practitioner and results will not be guaranteed by using other similar products on the market. Sometimes conditions and circumstances beyond the practitioners control may limit the ability to heal and so a full recovery may not be achieved.

Yes, I understand and agree to the terms of service.