{{isset($provider->first_name) ? ucfirst($provider->first_name) : ''}} {{isset($provider->last_name) ? ucfirst($provider->last_name) : ''}} {{isset($provider->middle_name) ? ucfirst($provider->middle_name) : ''}} {{isset($businessProfile) ? ucfirst($businessProfile->name) : ""}}

@csrf

Personal Information

Emergency contact

Referral source

How did you hear about this clinic?

@if(isset($practitionerIntakeForm) && $practitionerIntakeForm->health_history == 1)

Health History

If you have a history of any of the following conditions, please select below.

@if(isset($practitionerDisease)) @foreach($practitionerDisease as $disease)

is_checked == 1) checked @endif> {{$disease->name}}

@endforeach @endif

@endif

@if(isset($practitionerIntakeForm) && $practitionerIntakeForm->health_history_details == 1)

Health history details

@php $health_history_details = isset( $practitionerHealthHistory->health_history_details) ? $practitionerHealthHistory->health_history_details : ''; @endphp

@endif @if(isset($practitionerIntakeForm) && $practitionerIntakeForm->surgeries == 1)

Surgeries

@php $surgeries = isset( $practitionerHealthHistory->surgeries) ? $practitionerHealthHistory->surgeries : ''; @endphp

@endif @if(isset($practitionerIntakeForm) && $practitionerIntakeForm->medicines == 1)

Medicines/Supplements

@php $medicine_or_supplements = isset( $practitionerHealthHistory->medicine_or_supplements) ? $practitionerHealthHistory->medicine_or_supplements : ''; @endphp

@endif @if(isset($practitionerIntakeForm) && $practitionerIntakeForm->alcohol_consumption == 1)

Alcohol consumption

@php $alcohol_consumption = isset( $practitionerHealthHistory->alcohol_consumption) ? $practitionerHealthHistory->alcohol_consumption : ''; @endphp

@endif @if(isset($practitionerIntakeForm) && $practitionerIntakeForm->smoking == 1)

Smoking

@php $smoking = isset( $practitionerHealthHistory->smoking) ? $practitionerHealthHistory->smoking : ''; @endphp

@endif @if(isset($practitionerIntakeForm) && $practitionerIntakeForm->excercise == 1)

Exercise

@php $excersise = isset( $practitionerHealthHistory->excersise) ? $practitionerHealthHistory->excersise : ''; @endphp

@endif @if(isset($practitionerIntakeForm) && $practitionerIntakeForm->family_history == 1)

Family history

@php $family_history = isset( $practitionerHealthHistory->family_history) ? $practitionerHealthHistory->family_history : ''; @endphp

@endif @if(isset($healthHistoryQuestion)) @foreach($healthHistoryQuestion as $historyQuestion)

@endforeach @endif

@if(isset($practitionerIntakeForm) && $practitionerIntakeForm->current_complaint == 1)

Current complaint

Please provide more information about your current condition.

@if(isset($practitionerQuestions)) @foreach($practitionerQuestions as $question)

@endforeach @endif

@endif @if(isset($sectionQuestion)) @foreach($sectionQuestion as $squestion)

@foreach($squestion['section_question'] as $section_question) @if($section_question['type'] == 'button')

@else

@endif @endforeach

@endforeach @endif

Upload files

Please upload any files such as test results or x-rays that you wish to share with your service provider.

List of test results

@if(isset($is_practitioner) && $is_practitioner == 0)

Drag and drop files here

- or -

Save test result

@endif

@if(isset($practitionerIntakeForm) && $practitionerIntakeForm->private_health_fund == 1)

Private Health Insurance

If you have private health insurance that covers you for natural therapies, please provide your details below.

Please note, not all practitioners and/or services are eligible for rebates.

Health Fund

Fund name

Customer/Membership number

Patient number

Card issue number

@endif

Consent

@isset($practitionerIntakeForm->consent_treatment) {!! nl2br(e($practitionerIntakeForm->consent_treatment)) !!} @else {{ 'I have to the best of my knowledge, provided all relevant information about my health and medical history and I give my full consent to treatment. I intend this consent to apply to all future treatments and understand that I must update my service provider with any changes that may occur in my medical history. I understand that a 50% cancellation fee may apply if I do not provide at least 24 hours notice.' }} @endisset

Name

consent_full_name}}" name="consent_full_name" placeholder="Type full name">

@if(isset($is_practitioner) && $is_practitioner == 0) @endif

@if(isset($is_practitioner) && $is_practitioner ==1)

Download

@endif

Health history details

Surgeries

Medicines/Supplements

Alcohol consumption

Smoking

Exercise

Family history

{{$historyQuestion->header}}

List of test results

Uploaded

Private Health Insurance

If you have private health insurance that covers you for natural therapies, please provide your details below.

Please note, not all practitioners and/or services are eligible for rebates.

Health Fund

Fund name

Customer/Membership number

Issue Date

Patient number

Name

{{isset($provider->first_name) ? ucfirst($provider->first_name) : ''}} {{isset($provider->last_name) ? ucfirst($provider->last_name) : ''}} {{isset($provider->middle_name) ? ucfirst($provider->middle_name) : ''}} {{isset($businessProfile) ? ucfirst($businessProfile->name) : ""}}

Intake form

Personal Information

Emergency contact

Referral source

How did you hear about this clinic?

Health History

If you have a history of any of the following conditions, please select below.

Health history details

Surgeries

Medicines/Supplements

Alcohol consumption

Smoking

Exercise

Family history

{{$historyQuestion->header}}

Current complaint

Please provide more information about your current condition.

{{$squestion['header']}}

{{$squestion['introductory_text']}}

Upload files

Please upload any files such as test results or x-rays that you wish to share with your service provider.

List of test results

Uploaded

Private Health Insurance

If you have private health insurance that covers you for natural therapies, please provide your details below.

Please note, not all practitioners and/or services are eligible for rebates.

Health Fund

Fund name

Customer/Membership number

Issue Date

Patient number

Consent

Name