New Patient Intake Form

Already have an appointment? In the interest of saving a few trees, here is the option of completing your new patient intake form online rather than on paper in the clinic. It also saves time at your first appointment.

By submitting the form, you agree to the clinic's cancellations policy and acknowledge the information storage policy.

Cancellations: As a matter of respect, I require three (3) hours notice of cancellation to offer the appointment to other patients. Late cancellation and no-shows attract, respectively, 50% and 100% of the cost of the consultation missed. I also reserve the right to refuse further appointments.

Storage: Your information will always be stored securely with firewall and multiple-password protection. Your information will never be sold, distributed or published. Your medical history my be shared with other practitioners within the clinic, with your primary health care provider or emergency services should the need arise - if you object to this, please let us know.

Please complete the form below

Name *
At least one contact number, please
How you found out about the clinic
SMS reminders
The clinic offers free SMS reminders for appointments. This is not used for advertising or spam! If you'd like to opt out of receiving reminders, please check this box