Intake Form | UbuntuWellnessClinic

NEW CLIENTS

During your Initial Consultation, we will discuss your current health concerns, personal and family medical history, diet, lifestyle, and wellness goals. Your Practitioner will work with you to devise an individualised treatment protocol which may include cell food concentrates, herbal blends, nutritional supplementation, dietary and lifestyle suggestions.

This approach aims to address your current symptoms, while also considering strategies to address the underlying causes of your health concerns with the aim of helping you achieve long-term health and vitality.

Our Consultations are undertaken from the comfort of your own home or office via telephone. To book your Initial Assessment, please complete our Intake Form below and our team will be in touch to book your appointment.

Provides access to our Clinic
- Fee: $80 (non-refundable)

Includes

- Setup of account as a client of Ubuntu Wellness Clinic with your details provided to us.
- Initial one on one telephone consultation with one of our Certified Practitioners
- Access to our nutritional guidelines and additional support information.

Instructions

- Please read all questions on the intake form below and answer as best you are able.

- Once you make the payment (at the end of the intake form below) you will receive a payment submission confirmation email.

- Please ensure you check your spam/junk/promotions folder for your confirmation email.

Once we have processed your Intake Form, you will receive a phone call to arrange an appointment with one of our Practitioners.

The above process usually takes no more than around 5 working days.

Cancellation Policy

Please note that once you have booked an appointment with us it means that we have reserved time with our Practitioners exclusively for you. If you cancel your appointment less than 24 hours before it is scheduled to take place, you will be subject to a rebooking fee of $50. To avoid this fee, please provide cancellation notice at least 24 hours prior to your appointment. You can cancel or reschedule an appointment by emailing us at clinic@ubuntuwellnessclinic.com.au, or calling our office on 02 4926 1881

If you experience any difficulties, please call or email us for assistance:

Phone: 02 4926 1881 (10am-5pm Monday to Friday)

Email: intakes@ubuntuwellnessclinic.com.au

Please take time to read our Getting Started guide and Frequently Asked Questions prior to your Telephone Consultation, preferably with loved ones or any carers who may be assisting you.

We look forward to sharing your journey to wellness.

The Ubuntu Team.

1. & 2. Please first Signup to our website and create a free account using your email address and create your own private password.

3. Email (please use your sign up email address)

4. First Name

5. Last Name

6. Client Birthdate

7. Address

8. Address 2

9. Suburb

10. Postcode

12. State

13. Phone Number

14. Mobile Number

15. Carer Name (if applicable)

16. Carer Contact Details

17. Clients Weight

18. Client's Height

19. Client's Blood Pressure If Known

20. how did you hear about the Clinic ??

21. Client Marital Status

22. Parent Status (If client is a child)

23. Client Medicare Number

24. Client Private Health Insurance Details (If no private health insurance, type N/A)

25. Client Condition (Brief Diagnosis)

26. Client Condition (Detailed Diagnosis) Please list here your full medical diagnosis so that we can get a better understanding of your challenges, and create strategies for your success.

27. Date of Initial Diagnosis (for each Condition)

28. Client Vaccination History (List if known)

29. Client’s COVID-19 (Sars-Cov-2) Inoculation Type and History

30. Client's Doctor/Oncologist (Full Name)

31. Are any of your Medical Professionals supportive of Cannabis use as a medicine?

32. Client CURRENT Medications: Please list all CURRENT medications and recommendations by physicians. Include how long the clients been taking each, along with the dosage amount and times taken.

33. Client PAST Medications: Please list all PAST medications and recommendations by physicians. Include how long the clients been taking each, along with the dosage amount and times taken.

34. If a cancer diagnosis, is it oestrogen driven?

35. Are you on heart / blood pressure medication? If so, which one/'s? Please include how long, how much and times taken.

36. Are you/client on Warfarin? Is so, for how long, how much and times taken?

37. Has a close family member had diabetes, cancer, heart disease, high blood pressure, stroke or high cholesterol? If yes, please advise

38. Any PAST experience of mental health issues? If so, please advise the condition/s and also list all past relative medications.

39. Any CURRENT experience of mental health issues? If so, please advise the condition/s and also list all current relative medications:

40. How is the client feeling emotionally right now? Do you have support from family and friends?

41. Does client have any known medical or food allergies?

42. Please rate the client's pain level on a scale from 1 - 10

43. Is the client experiencing trouble sleeping?

44. Does the client exercise? If so, what type, and for how long?

45. What does the client have for Breakfast -- Lunch -- Dinner -- Snacks? Please list a typical 'food' day:

46. How much water does the client consume daily?

47. What type of water is consumed? (eg's tap water, spring water etc)

48. Is the client taking any dietary supplements?

49. Does the client do any sort of activities to help relieve stress? Mindfulness, yoga, meditation?

50. Does client consume alcohol? ( Y / N ) how many / how often?

51. Does client smoke cigarettes? ( Y / N ) how many / how often?

52. Does client take non-prescribed drugs ? ( Y / N ) if yes – please list

53. Have you had any previous experience with Cannabis and if yes, what is that experience?

54. What is your reason for coming to this clinic? What is your main goal or objective?

55. Would you like to receive appointment communications by sms to your mobile phone (enter yes or no)?

UBUNTU

Wellness Clinic

NEW CLIENTS

UBUNTU
Wellness Clinic

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Ubuntu Wellness Clinic proudly acknowledges the Traditional Custodians of country throughout Australia and recognises their continuing connection to land, water and community. We pay our respects to them and their cultures, and to Elders past, present and emerging.