Patient Information Form


New Patient Information Form

  1. Chronic Initial
  2. Acute Initial or Musculoskeletal

Dr Debbie Smith patient intake documents

Dr Debbie Smith

Dr Debbie Smith

1.  Chronic Initial Patient  – Condition longer than 3 months

Download both documents
The forms should be emailed back to the practice before your appointment – ideally 24 hours before your appointment. Email to:

b.  Point of Origin – HAQ-health-appraisal-questionnaire-complete


 2.Musculoskeletal Initial Patient &  Acute Initial Patient  – Condition less than 3 months


DrDebbie – New Patient Intake Form Musculoskeletal and Acute V15_2018-1



DR SANDRA SQUARA new patient documentation




Dr. Debbie Smith and Dr Sandra Squara , Homeopaths recognize the importance of protecting the privacy of your personal and medical information. During a visit to our practice your privacy is respected. As well as all details given via any medium/platform to us.

We do not collect personal information about you unless you voluntarily choose to provide it to us.  This would be the case if you provide us with your information for the purpose of registering you as a patient, providing a payment, or sending us an e-mail, in which you voluntarily provide your name, contact information and medical history. Our staff requires certain information to contact your medical aids or respond to queries. We do not use this information for any other purpose. We protect all personal information in our custody with strong security safeguards, including strict access controls.

Disclaimer for using this website

Although we make every effort to ensure that all information posted on our website/facebook is accurate and complete, we do not represent that it is so, or guarantee it, and accept no liability or obligation for accuracy or completeness. We reserve the right to update the information as necessary without notice. If there is any discrepancy between information posted on our website and the original paper version, the original paper document prevails. As this website/facebook is for information purposes only, you should seek appropriate, qualified advice before acting or omitting to act based upon any such information.

Our servers automatically log information about visits to our website in the normal course of establishing and maintaining web connections. Server logs record statistical information, such as time and duration of visit, pages requested, and browser types. These statistics are reported in aggregate forms to our communications staff. This information does not personally identify you. We do not link server log information to any other data in a way that would enable us to identify individual visitors. This tracked information will not be used by any other organization.