New Patient Intake Form

Please complete this form prior to your initial consultation. By submitting this form you agree to the use of your personal/health information by Herbalwell to assess your health and provide treatment here via the form and within future consultations. 

To book your consultation head to the Bookings Calendar. If you would like to see me in person in Woollahra, please call me or email me and I will gladly organise a time for you. I look forward to meeting you soon, Sulin.

Selected Value: 1
1 is lowest, 10 is highest. Estimate your best daily energy level from 0 - 10.
Selected Value: 1
1 is low stress or MILD, 5 is highest stress or SEVERE. Estimate your stress level from 1-5
Price: $10.00
Zinc deficiency is associated with hormonal irregularities including irregular cycles, menstrual issues in girls and teens, skin conditions, stunted growth in childhood and more. You are not obligated to have your zinc assessed on the day, this is more to help me plan any testing requirements prior to the consulation.
I give permission for my personal information from this form and in the forthcoming consultation/s to be kept on file for the purpose of naturopathic treatment. I understand all reasonable steps will be taken to keep my personal information confidential. I understand Sulin Sze on behalf of Herbalwell is a naturopath and herbalist, not a medical doctor. I understand that all information given in written and/or verbal form to Herbalwell is strictly private and confidential. I agree to pay any outstanding invoices from Herbalwell for services rendered promptly as per the invoice terms.
Thankyou for completing this form. Please indicate if you have booked already, or plan to book a consultation. You can also request a call to book you in for an In Person Consultation in Woollahra or Northern Beaches. I look forward to seeing you soon! Sulin
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