Please complete all details below
Move the circle to the area of greatest concern
You can skip this step, but this assists your provider with in-session identification.
Please indicate if you have ever had (check all that apply):
During the past year have you experienced any of the following (check all that apply):
Have you ever had any of the following (check all that apply):
Select if any of your biological parents or grandparents had any of these conditions (check all that apply):
List all current medications, and how you take it:
Indicate the nature and date of any surgeries you have had:
Indicate other details which would be useful for your specialist in understanding your needs:
You will be able to change these details at any time using the link for Medical Details in your welcome email. All accesses to these details are monitored and you will receive a notification every time you access these medical details.
Connect with your phone, tablet or computer. You should receive an email with your appointment details. We will remind you via email and text message on the day of your appointment to join the session.