Youform

Welcome back! Loading your previous answers...

Marshland intake form

The next questions help me to understand more about your situation. Once you submit, I’ll be in touch with the next steps.

Let's begin with your basic details...

Full name

Pronouns

Phone Number

Date of birth

press Enter ↵

Never submit passwords Report abuse

'Oops! something went wrong.',

Please enter your postal address

This is where I will send your herbal medicine packages

Address

Post code

Country

press Enter ↵

Never submit passwords Report abuse

'Oops! something went wrong.',

Main health concerns and symptoms

Please also include how long these have been present and any previous treatments

press Enter ↵

Never submit passwords Report abuse

'Oops! something went wrong.',

What is your relationship to your body and health?

share anything that comes to mind...

press Enter ↵

Never submit passwords Report abuse

'Oops! something went wrong.',

What do you hope to get from working together?

Your priorities for this journey (e.g., reduce flare-ups, help with my stomach hurting, rebuild trust with body, understand patterns etc)

press Enter ↵

Never submit passwords Report abuse

'Oops! something went wrong.',

Please list any medications you are taking

Please include dose, reason for taking, duration of use and any past medication you have been on long term. Please note any frequent antibiotic use.

press Enter ↵

Never submit passwords Report abuse

'Oops! something went wrong.',

Do you have any diagnosed conditions?

This can include anything self diagnosed

press Enter ↵

Never submit passwords Report abuse

'Oops! something went wrong.',

Upload any relevant documents

If you have them, you can upload any relevant documents (blood tests, scans, reports) here.

You can drag & drop or paste as well

Maximum file size: 10MB

press Enter ↵

Never submit passwords Report abuse

'Oops! something went wrong.',

Which day works best for you for meeting? 👇

Monday

Tuesday

Wednesday

Friday

press Enter ↵

Never submit passwords Report abuse

'Oops! something went wrong.',

Anything you need me to know about your accessibility / special requirements needs?

press Enter ↵

Never submit passwords Report abuse

'Oops! something went wrong.',

Anything else you would like me to know?

press Enter ↵

Never submit passwords Report abuse

'Oops! something went wrong.',

𓅣 Thank You So Much 𓅣

I’ll be in touch on my next working day
to guide you through the next steps.
Lauren ☺️

This form was created for FREE using Youform.

Create your own Youform