Full Name:
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth:
*
MM
DD
YYYY
Phone:
*
Country
(###)
###
####
Email:
*
Emergency Contact Name / Relationship:
*
First Name
Last Name
Relationship to Emergency Contact
*
Emergency Contact:
*
Country
(###)
###
####
Reason for your Consultation:
*
Briefly describe your Symptoms / When did your symptoms begin?
*
Medical History (briefly detail):
*
Family Medical History (briefly detail):
*
Current Therapies (if any):
*
Past Therapies (if any):
*
Allergies (if any):
Current Medications and/or Supplements or Prescriptions (if any):
Are you a Smoker?
*
Yes
No
Previously
Do you drink Coffee?
*
Yes
No
Do you drink Alcohol?
*
Yes, I drink daily
No, I do not drink
Occasionally
How much Water do you drink daily?
*
How many hours Sleep do you get?
*
List your additional sleep habits? Do you have difficulty falling asleep? Do you wake during the night? Do you Wake refreshed?
*
Menstrual Cycle / Hormonal Changes (if relevant) Flow: Regular / Light / Heavy / Average. Length, if Pain, PMT, Colour/ Clotting:
*
Bowel Movements (briefly detail), Regularity, if any Constipation/ Diarrhoea:
*
Referred By:____ /or How did you hear about us?
*
Additional Information Relevant or Questions prior (if any):
Legal Information: By checking the box below I agree to the following terms of my treatment:
*
1. If you desire diagnosis for a symptom we recommend you seek the services of a medical professional. By law Lauren may not provide a medical diagnosis or recommend discontinuance of medically prescribed treatments.
2. The provision of Lauren’s services entails the collection and recording of personal information relevant to your current situation. This information is a necessary part of your assessment and treatment protocol.
3. ACCESS: Any information gathered, recorded, and filed is available upon request. Confidentiality: All personal information gathered during the session shall remain confidential and secure except if: (1.) It is subpoenaed by a court, or (2.) Prior approval has been obtained to: Provide a written report to another professional or agency. e.g. a GP or a solicitor, or Discuss the material with another person. e.g. a parent or employer.
4. CANCELLATION POLICY: The appointment time reserved for you is exclusively for you. We require a 48-hours notice of cancellation. If you must cancel, or reschedule, an appointment due to an emergency, please notify us as soon as possible, we understand that things do happen. If you do cancel with less than 24 hours notice, 50% payment of the session cost is required. Thank you for your consideration and understanding.
5. LATENESS POLICY: Lateness of more than 15 minutes results in cancellation of appointment, unless otherwise agreed upon.
6. NO SHOW: In the event of a no call/no show situation, in addition to Cancellation/Lateness Policies, the client will be charged for the full session cost.