New Client Form

Please fill in the form before your Initial Consultation

HEALTH ALERT – If you are experiencing any symptoms of fever, cough, sore throat, shortness of breath etc, please contact the clinic and cancel you appointment. 

Instructions:

Please fill out all fields to the best of your knowledge. Ensure the fields marked “required” are filled in correctly.

Please make sure you ‘click’ the box to agree to the terms and conditions and click the send button at the bottom of the page.

You will see a green confirmation box appear below the “send” button to confirm the form has been filled in correctly and sent.  If the green box does not appear, please check the form as you will have missed filling in a field.

We Take the privacy and security of your personal information very seriously. Click the link to read our Privacy Policy.

Clients under 18yrs old MUST be accompanied by a parent|guardian to each consultation

Personal Details

Please fill out all fields

Lifestyle Information

Medical History

Please select if you have any of the following:

Please list names and dosages if known

please read the linked documents before continuing.


Terms and conditions


1. I hereby request & consent to the performance of Acupuncture treatments & other Traditional Chinese Medical (TCM) procedures. I understand that methods or treatment may include, but are not limited to: acupuncture, cupping, electrical stimulation, herbal products (Chinese &/or western), nutritional & exercise advice.

2. I understand that acupuncture is considered a safe method of treatment, but occasionally there may be some bruising or tingling near the needling sites that last up to a few days.

NO SHOW/MISSED APPOINTMENT POLICY

-$30 Missed Appointment/No-Show Fee-

I understand that sometimes you need to cancel or reschedule your appointment and that there are emergencies. If you are unable to keep your appointment, please call the clinic on 9796 2388 as soon as possible (with at least a 12-24 hours notice).

Whilst I believe it is the responsibility of the client to remember the appointment times they made, I can set-up an email reminder system if requested. This will send you a reminder of your next appointment 3 days prior, then the night before your appointment. Please mention if you require this facility on your account at your next appointment.

I have no issue with clients being unable to attend their appointments due to circumstances beyond their control, as long as some form of notice is given.  If a client fails to attend their appointment without notice then they will be documented as a “no-show”. The policy of which is detailed below:

 

PLEASE REVIEW THE FOLLOWING POLICY:

  1. Please cancel or re-schedule your appointment with at least a 12-24 hours’ notice: This will allow another client who may be very unwell to take your place and come in for treatment.



  1. If you do not present to the clinic for your appointment, it will be documented as a “No-Show” appointment.



  1. After the first “No-Show/Missed” appointment, you will receive an SMS or email warning that you have broken our “No-Show” policy. I will then happily assist you to reschedule this appointment if needed. I will also automatically add the email reminder service to your account to try and prevent this re-occurring.



  1. If you have 2 “No-Show/Missed” appointments within a one-year time period, you will receive an email from our office and will be billed a $30.00 no show fee.



  1. Each subsequent no show within a one-year period will result in a $30 no show fee.






Please understand that not attending appointments denies other ill patients the opportunity to receive timely treatment.

I hope this helps you understand your responsibility to plan appointments accordingly and notify the clinic appropriately if you have difficulty keeping your scheduled appointments.

Thank you for your cooperation

Dr. Steven Orloff

At the start of each season I send out a short email to my clients with some health, food and life advice from a Chinese Medicine perspective.

October 18th Update - From Monday October 19th the clinic will be operating as normal with a COVIDsafe plan as before.

Thanks to the amazing work done by all Victorians we can slowly come out of this lockdown. As announced by the health minister, routine treatments can resume. The clinic is now no longer restricted in the symptoms we can treat. Feel free to book online or call the clinic on 9796 2388