test – Vibe Natural Health

Patient Registration

Your Details(Required)

Title First Last Preferred Name

Date of Birth(Required)

Occupation(Required)

Gender(Required)

Email(Required)

Phone(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Next Of Kin - Name

Relationship

Phone Number

Emergency Contact - Name(Required)

Relationship(Required)

Phone Number(Required)

Do you Identify as:(Required)

Aboriginal

Torres Strait Islander

Both

Neither

Medicare Number

Expiry Date

Reference

Pension / Health Care Card

Expiry Date

Dept. of Veterans' Affairs

Expiry Date

Current Medications

Past Medical History

Past Operations

Alcohol

Non Drinker

Drinker

Smoking:

Currently smoking

Ex-smoker

Non-Smoker

Vaping / E-cigarettes

How often do you exercise vigorously?

Based on the above question, how long would you exercise for?

10-15min

15-30min

30-60min

+60min

Height

Weight (kg)

Waist (cm)

Covid Vaccinated

Up-to-date

Pending

Unvaccinated

Interested in discussion regarding booster vaccination

Family History

Diabetes

Asthma

Heart Disease

Cancer

Other

Cancer Screening

Bowel Screening

Cervical Screening

Breast Screening

Any Other Information:

Patient Authority(Required)

I have provided a full and detailed medical history that is up-to-date and accurate as far as practical

I have read the information above and consent to the collection and use of the information provided

I am aware of my rights to access the information collected about me except in some circumstances where this information may be legitimately held (with a supporting explanation)

I consent to the handling of my information by the practice for the purposes listed above

Patient Name(Required)

First Last

Date(Required)

We give you the opportunity to participate in your health care and be in control of your health. We give you practical and easy tools to improve your energy levels and overall physical and emotional fitness.

Navigation

Our Services

Contact Info

Our Hours

Mon-Fri: 8:30am to 7:30pm
Sat: 8:30am to 3:30pm
Sun: 8:30am to 3:30pm (Appointments Only)

After Hours Medical / IV Infusion Services

Mon-Wed: 6pm to 9pm
Sat: 8am to 5pm
Sun: Appointment Only