Intake Form | UbuntuWellnessClinic

GP REGISTRATION

(NEW CLIENTS ONLY)

If you are a pre-existing client of Ubuntu Wellness Clinic, please note that you already have access to the services of our GP and we do not require you to fill in a registration form. Please contact the Clinic on 02 4050 0315 to book an appointment.

If you live in the greater Newcastle region and are seeking access to a traditional GP who respects your rights to privacy, informed consent, and who upholds the highest moral and ethical principles, then please register to be added to our books by completing the form below.

We charge an administration fee of $30 per person to register as a client of the Doctor's Surgery.

Should you wish to seek assistance from one of our professional consultants (as well as receive complementary registration with our GP), please instead fill in our Wellness Clinic Intake Form.

Note* The doctor does not write scripts for Medical Cannabis but can supply a supporting letter if scripts are arranged through us.

Provides access to our Doctor's Surgery

- Fee: $30 (non-refundable)

Includes

- Setup of account as a client of the Doctor's Surgery with your details provided to us

- Ongoing access to GP services

- Acess to our Wellness Range of products

Does NOT include

- Any consultation with ourprofessional consultants

- 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 Registration Form, you will receive a phone call to arrange an appointment with the GP.

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

Phone: 02 4050 0315 (9am-4pm Weekdays & 9am -2pm Weekends)

87 Young St

Carrington

NSW 2294

Email: intakes@ubuntuwellnessclinic.com.au

GP REGISTRATION FORM

1. & 2. Please sign up to our website (top left corner) and create an account using your email address and a 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)?

GP REGISTRATION

(NEW CLIENTS ONLY)

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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.