This form is for you to use to request a consultation for yourself or on behalf of someone else - perhaps a child, friend, parent or loved one who would have difficulty doing it for themself. For this reason we have referred to the person who the consultation is for as a "patient" - this is simply to clarify the process of completing the form. In this form the use of the word "patient" does not infer anything whatsoever about any individual's legal or medical condition or situation.
I assure you that I treat this information with the same confidentiality and respect that I have for all my clients' information whether collected in my clinic or online. I will not use any of this information for any purpose other than to help me assess your health situation and to identify useful treatments or dietary regimes.
Please complete the form below as fully as you can,
coloured fields show information that is necessary for me to effectively undertake the health assessment which forms the basis of the online consultation. The address fields are needed so that we know where to send any medicines should your condition require them.
coloured fields are optional and can be left blank if you wish.
If you move your mouse over the you will see a tooltip explaining the information I need in more detail.