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What is a Clinical Herbalist
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About Us
What is Herbal Medicine
What is a Clinical Herbalist
Services
Testimonials
FAQ
Blogs
Book Now
Contact
"A Call to Health, Naturally"
New client form
Name
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First Name
Last Name
Mobile Phone
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Date of Birth
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Email
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Address
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Address 1
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How did you hear about us?
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Word by Mouth
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Main presenting health concern
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Current Medications or supplements
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(name, dosage and frequency)
Known Allergies or Intolerances?
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Your Medical History - please check all that apply:
Asthma
Anxiety
Autoimmune disease
Cardiovascular
Chronic fatigue
Depression
Diabetes
Eczema/Dermatitis/Psoriasis
Fertility
Hypertension
High cholesterol
Hormonal issues
IBS/IBD
Previous/current cancer
PMR
Thyroid issues
Please check any relevant symptoms:
General Health
Anaemia
Constantly sick
Fatigue
Headaches
Infections
Insomnia
Joint problems
Low mood
Muscle aches and pains
Poor concentration
Skin rashes/dryness
UTI
Digestion
Bloating
Abdominal pain
Indigestion
Reflux
Constipation
Diarrhoea
Discomfort/pain
Respiratory System
Chronic cough
Sinus congestion
Hayfever
Wheezing
How many hours sleep on average do you get?
0-4
4-6
6-8
How would you rate your stress out of 10
(10 being high)
1-2
3-4
5-6
7-8
9-10
Family Medical History
e.g hypertension, diabetes, cancers, stroke, depression etc
Any other information you like to share
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Consent and disclaimer
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DP Herbals uses only the highest quality herbs and supplements when treating my current condition. They are prescribed at therapeutic doses and can only be dispensed by a registered and qualified practitioner. They are not intended to replace current prescribed allopathic medication unless discussed first with my GP. I fully understand that Clinical Herbal Medicine, like any treatment, can potentially have adverse side effects. However, such occurrences are rare, and are further minimised by regular monitoring by my Practitioner. I am guaranteed an improvement in my current health status as long as I follow the treatment plan that is created for me. I understand that results vary from individual to individual and that it may take from 4-8 weeks before I clearly start to notice health giving benefits. It is understood that clinical herbal medicine works well over time allowing the body to restore its own natural balance. Payment in full is due on the day or if agreed within 7 days of invoice issued. If payment is not made by then, a debt collection agency will be conscripted for the amount owed unless discussed in advance with DP Herbals. I have read and understood the above agreement.
I agree
Thank you!