COMO NATURAL MEDICINE
CONFIDENTIAL
NEW CLIENT QUESTIONNAIRE
1. PERSONAL DETAILS; Please write in block letters.
Title: Dr Mr Mrs Ms Miss Master
First Name:__________________
Last Name:________________________
Address:_________________________________________________________________
Post Code:______________ Home Phone:_____________________
Business Phone:________________ Mobile Phone:____________________
Email:_____________________________________________ Age:____________
Date of Birth:______/______/__________ Do you smoke? Y / N
Marital Status:_________________ Occupation:______________________________
Name of Private Health insurer:_____________________________________________
How did you hear about Como Natural Medicine? __________________________________
2. MEDICAL DETAILS; Please give as much information as you can.
Your presenting complaint is?________________________________________________
How long have you had this condition? ________________________________________
Do you have any other problems?___________________________________________
________________________________________________________________________
Previous medical history (including any pathology results and/or Xrays)
________________________________________________________________________
________________________________________________________________________
Any known transmittable diseases? Y / N
Previous surgical history:______________________________________________
Current medication either Doctor or self prescribed:___________________________
________________________________________________________________________
The following are the terms and conditions of Como Natural Medicine.
Accounts
All accounts are rendered and payable at the time of consultation, otherwise an account fee of
$5.00 is charged.
Payment is by cash, cheque or eftpos.
Cancellation of Appointment
It is vital that we are given 12 hours notice of any cancellations.
If you do not keep your
appointment and fail to notify us you may be charged a $25.00 cancellation fee - this is because
your time could have been allocated to another patient.
We appreciate that circumstances can
arise which prevent you from keeping appointments, if this happens to you, please contact us as
soon as possible to explain your situation and the cancellation fee may be waived.
I agree to accept the above conditions as a patient of Como Natural Medicine.
Signed:____________________________________
Date:______________________________________
© 2011 Como Natural Medicine www.comonatmed.com.au
