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Initial Consult IPEC
I offer distant healing to people all over the world. Your physical address is required on the form in order for me to establish the time difference between us.
Personal Information
All information shared will be kept confidential
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Your name
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Your surname
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Address
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Suburb
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Postal code
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Country
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Contact number
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Email address
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Occupation
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How did you hear about our clinic?
If referred, please indicate who referred you
Health Information
All information shared will be kept confidential
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Please list health concerns in order of importance and specify how long you've had each one
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Please specify known allergies/sensitivities
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Please list any life threatening allergies (eg. anaphylaxis)
Do you have any pets? If so specify
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Any past injuries/surgeries?
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Do/have you smoke(d)? If So How long? How many?
Are you under emotional stress? Please Specify
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Are you currently taking any medication? If yes, please list them and the condition you're taking them for
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Please list any natural supplements you are taking, for how long, the dosage and condition
Waiver and Consent
I understand that this practice aims to assist me with my healthcare. Most allergens only require one treatment per allergen, however on some occasions more than one treatment is necessary. No one therapy is for all. If no change is observed within a few treatments, your practitioner will refer you on to a more suitable therapy for you. A small percentage of patients may experience tiredness or headache developing after the treatment and lasting usually not longer than 24 hours. If more severe reaction occurs it is the patient’s duty to contact the clinic or practitioner. It is possible that your symptoms may be aggravated. This is uncommon, but may happen if a specific allergen hasn’t been entirely cleared or other allergens may be causing stronger reaction. I acknowledge that IPEC therapy is not a substitute to a medical or/and psychological treatment. I declare that all the information I have given is correct and I have answered the questions to the best of my knowledge.
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I accept the above terms
Please tick for acceptance
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Today's Date