Name *

Date of birth *

Address, suburb, state & postcode *

Home phone

Work phone

Mobile

Email address *

Would you like to receive our newsletter? * Would you like to receive our newsletter? *YesNo

Do you have any specific skin issues you would like to address?* *

What are your symptoms? Please list: *

Has this condition been medically diagnosed? If so, by whom & when? *

How long have you had this condition / symptoms for? *

What treatment(s) have you received / tried in the past for this? *

What doctor prescribed / over-the-counter medications are you taking? Please state medication name, strength, dosage, date of first use & reason for taking

Informed consent for naturopathic care Informed consent for naturopathic care I declare the information above is true and correct and indemnify Inside Out Clinic of any liability for any false or misleading statements given. I understand and accept that the naturopathic treatment received by your office is of a holistic, therapeutic nature and does not attempt to diagnose or treat disease. I understand and accept that data collected about myself during this consultation and subsequent consultations will remain the property of Inside Out Clinic, as part of case history records. This information will remain private and confidential.