Who is this form for?
If you are (or the patient is) over 10 years, please complete this Information Form.
If the patient is under the age of 10 years, please complete the Child Information Form.
What to do?
To help Dr Mullins to prepare for your consultation and to give him an idea of your important issues, you'll need to complete this Intake Form.
Please ensure that you complete this form at least 48 hours before your scheduled consultation (but preferably once you make an appointment).
Because you'll be able to hit the ground running (so to speak) and make the most out of your time with Dr Mullins. There will be a lot of information shared and a plan created for your next steps.
How long will it take?
What do you need?
*If you're completing this form on behalf of someone else, please note that the questions relate to the patient (not you) and should be answered about the patient's circumstances.
Referring doctor information
Your major concerns
Diet and nutrition
For this next part, please list the amount of drinks that you have on an average day
Head, nose and sinus issues
Chest, breathing and heart
Stomach and kidneys