New Patient Registration To check if you are eligible for our services, please fill out this form. Do you have a medical condition that has been diagnosed by a registered medical practitioner or GP? * If you have not been diagnosed or tried any prescribed medications you may not be eligible. Yes No Have standard medications/treatments been unsuccessful in treating your symptoms appropriately OR do you experience adverse side-effects? * Yes No Please upload your health summary: FileField; MaxSize=10000 KB; Multiple; addText=Upload_Your_Files Please upload your doctor referral: FileField; MaxSize=10000 KB; Multiple; addText=Upload_Your_Files First Name * Surname * Date of Birth * MM DD YYYY Postal Code * Phone * Email * Please input your email address. This email will also be used for your account creation once approved. How did you hear about us? (Optional) Thank you for submitting your new patient registration form. We will be in touch with you soon.
