Patient Details and Informed Consent Form

For new patient, please fill the following ‘Patient Details and Informed Consent’ Form prior to your first online consultation.

Please read the following carefully before filling the form. Please feel free to contact Shirley if any concerns or questions.

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Informed Consent

Chinese Herbal Medicine and therapies offered by Shirley have a long history of safe practice, however, there are always some risks associated with any sort of treatment.

Below is a list of potential risks associated with therapies offered by Shirley. The best way to reduce the chance of risk occurring is to answer all questions about your health fully and honestly. We will explain all treatment to you before we commence them but you must ask if you require further explanation or have specific questions.

 Therapy Outline of possible risk  Strategies to minimise the possible risk
 Chinese Herbal Medicine Drug Herb Interactions  It is important to tell Shirley about all medications and herbal or nutritional products that you are currently taking or recently stopped.
 Chinese Herbal Medicine  Allergies  It is important to tell Shirley any form of allergies (mild or severe) you ever experienced or suspected.
 Basic Counselling  Feeling emotional  It is important to tell Shirley how you feel. If emotions are too overwhelming, there might be a need for referral.

 

When you finish filling the form, please remember to ‘tick’ the last item to agree to under treatment. Once you submit this form, it indicates that you have read the above table, and will corporate with Shirley to take steps to minimise the potential risk.

Please be aware that the information collected in this form is required in order to provide you with appropriate and best health care services and failure to answer all questions will affect our ability to deliver these services to you. thank you for your time.

[contact-form subject=”Shirley Chong ” to=”shirlchong@gmail.com”] [contact-field label=”Full Name” type=”name” required=”true” /] [contact-field label=”Email” type=”email” required=”true” /] [contact-field label=”Date of Birth” type=”text” required=”true” /] [contact-field label=”Place of Birth” type=”text” /] [contact-field label=”Occupation” type=”text” /] [contact-field label=”Marital Status” type=”select” options=”,Prefer not to answer,Married,Partnered,Separated,Divorced,Widowed” /] [contact-field label=”Address” type=”textarea” required=”true” /] [contact-field label=”Phone number” type=”text” required=”true” /] [contact-field label=”Health Insurance” type=”text” /] [contact-field label=”Next of Kin / Emergency contact details (include relationship to patient and contact details” type=”textarea” required=”true” /] [contact-field label=”Name and location of your usual doctor, other health practitioners and/or pharmacy” type=”textarea” /] [contact-field label=”Do you consent to us contacting your doctor/ health practitioner/ pharmacist to discuss your health and medications? ” type=”radio” required=”true” options=”Yes,No” /] [contact-field label=”Please list all the prescription medications that you are currently taking or recently stopped” type=”textarea” required=”true” /] [contact-field label=”Please list all the vitamins/ minerals/ supplements/ herbs that you are currently taking or recently stopped” type=”textarea” /] [contact-field label=”Do you have any allergies sensitivities to any foods, medications or any substance? ” type=”radio” required=”true” options=”Yes,No” /] [contact-field label=”If YES, please list all allergies / sensitivities” type=”textarea” /] [contact-field label=”Is this your first time to see a Chinese Herbal Medicine Practitioner?” type=”radio” required=”true” options=”Yes,No” /] [contact-field label=”Please tick if you have or have ever had any of the following. If not listed below, please indicate here. ” type=”text” /] [contact-field label=”Diabetes” type=”checkbox” /] [contact-field label=”Cancer” type=”checkbox” /] [contact-field label=”Hepatitis” type=”checkbox” /] [contact-field label=”HIV/ AIDS” type=”checkbox” /] [contact-field label=”Asthma” type=”checkbox” /] [contact-field label=”Heart Disease” type=”checkbox” /] [contact-field label=”Depression or Chronic Fatigue” type=”checkbox” /] [contact-field label=”Do you take anticoagulants?” type=”checkbox” /] [contact-field label=”Are you pregnant or planning to get pregnant” type=”checkbox” /] [contact-field label=”Any other concern or conditions you want to tell Shirley” type=”textarea” /] [contact-field label=”I understand the risks as stated above this form are possible and agree to under treatment” type=”checkbox” required=”true” /] [/contact-form]