This information provided by you will be treated as strictly confidential and will not be shared with any other party.
Your date of birth
Please indicate if you have taken the COV19 injection:
When was your COVID vaccination:
Please provide current symptoms or issues you are experiencing
Are you currently under the care of a doctor or hospital for any condition(s)?
If so, please give brief details
Name of family Doctor
Have you been clinically diagnosed with any medical conditions in the past?
If yes, what medications are you currently taking?
Are you pregnant or trying to become pregnant?
Have you undergone recent surgery?
Do you suffer or experience any of the following symptoms?
FatigueHeartburn/indigestionConstipationHeadachesDizzinessSugar cravingsMood swingsDepressionDry skinSleep issuesPainDiarrhoeaHay feverBloating/flatulenceEczemaNauseaNumbnessOther
How would you describe your appetite?
Do you eat three meals a daily?
What nutritional supplements do you take on a regularly basis?
TERMS & CONDITIONS
I appreciate that Kinesiologist Practitioners do not give medical diagnosis or treatment.
I am fully responsible for the option of ordering and taking my chosen supplementation.
I understand that my G.P is medically responsible for the care of my dependents and myself and that it is fully my responsibility to inform my doctor of any supplement or lifestyle changes I am making.
My time is valuable. Please let me know if you cannot keep an agreed appointment so I can firstly re-schedule with you and secondly offer your therapy session to someone else in need.
A cancellation fee of $30 will be required if you cancel your appointment without sufficient notice for me to fill your spot. (less than 24 hours of your booked appointment time)
I agree to these terms and conditions and cancellation policy
Designed and built by Tuatara Design
© 2022 Replenish Kinesiology. Built using WordPress and the Mesmerize Theme