Intake Form | UbuntuWellnessClinic

REVISED CONSULTATIONS

Should your health concerns change, or if more than 12 months has passed since your last consultation, you will be required to book a 45-minute Revised Consultation. Your Practitioner will conduct a thorough re-assessment and devise a new treatment protocol for your current requirements.

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

Provides access to our Clinic
- Fee: $70 (non-refundable)

Includes

- 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 Revised 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. First Name

2. Last Name

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

4. Preferred Contact Number

5. Current Address (if it has changed).

6. Clients Weight

7. Client's Blood Pressure If Known

8. Client Condition (Current Diagnosis)

9. Client Condition (Details) Please provide further information about any changes to the client's condition, or any new diagnoses that we should know about.

10. Have there been any other significant changes in the client's life?

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

12. If you are still using your Ubuntu oils, please provide us with your current formulas, dosage schedule, and how many drops of each you are taking (Morning/Afternoon/Night).

13. If you are no longer using your Ubuntu oils, please tell us when and why you ceased taking them.

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

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

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

17. Is the client experiencing trouble sleeping?

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

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

20. How much water does the client consume daily?

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

22. Is the client taking any dietary supplements?

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

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

25. Is there anything else you would like to share to assist your Consultant?

26. What is the client's current health goal?

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

REVISED CONSULTATIONS

Join our mailing list

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.