Bundoora Clinic

NEW PATIENT INTAKE FORM

Upon successful completion, you will be directed to our online bookings form to book your first appointment.

All information will be stored securely to ensure your privacy and is 100% confidential

Personal Details

Name(Required)
DD slash MM slash YYYY
Address(Required)

Main Complaints

Have you been given a diagnosis for these problems by a GP or Specialist?(Required)

Personal Medical History

(Please include your childhood history)
i.e. motor vehicle accidents, fractures, etc.
Please describe
Please list all medications, herbs, vitamins and over the counter drugs.
Please list any foods, drugs, medications or environmental factors which you are sensitive or allergic to.

Declaration

I understand that in all forms of health care there may be some very slight risks as a result of acupuncture treatment.

These may be:
  • Not uncommon – itchiness at needle insertion site, minor bleeding, dull achy feeling possibly lasting up to 2-3 days.
  • Occasionally – temporary exacerbation and/or aggravation of symptoms.
  • Rare – Pneumothorax, nerve pain, punctured organs, hematoma and needle shock.