New Client Information

Please tick if you are filling this form out on behalf of another

I am over 18yrs old – filling this form in on behalf of another adult

I am the client’s Parent|Guardian (Client is under 18yrs old)

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

Name

Phone Number

Parent|Guardian Name

Parent|Guardian Phone Number

Personal Details

Please fill out all fields

First Name(required)

Last Name(required)

Gender

Date of Birth(required)

Occupation

Stress Level

Address(required)

Suburb(required)

Postcode(required)

Email address(required)

Home Phone Number

Mobile Number(required)

Health Fund

Emergency Contact Name(required)

Emergency Contact Ph(required)

How did you hear about us?(required)

Search Term you used:

Ailments you are seeking treatment for(required)

Lifestyle Information

No. Exercise sessions per week

Avg hours sleep per night

No. of glasses of water per day

No. of Coffees/Teas per day

No. of Soft drinks/Energy drinks per day

Alcohol Consumption

Diet Type

Food Allergies

Lactose

Fructose

Gluten

Other

Food Allergies Other:

Do you skip breakfast?

I agree to the Terms & Conditions | Cancellation Policy

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

-$50.00 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:

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.

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

You will receive an email from our office and will be billed a $50.00 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

Quarterly Email Newsletter

Yes add me to your mailing list

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.

COVID19 Agreement(required)

I am currently not showing any symptoms such as cough, fever, shortness of breath.

I agree to immediately cancel/reschedule my appointment(s) if I begin to show any suspected COVID19 symptoms or return a positive test result.

This field should be left blank

Personal Details

Lifestyle Information

Medical History

Terms and conditions