Get Dr Dominique Wells

Completing the Dr Dominique Wells new patient registration form is a straightforward process designed to streamline your onboarding experience at NIIM Gold Coast. This guide provides a detailed step-by-step approach to ensure you accurately fill out the necessary information online.

Follow the steps to successfully complete the registration form.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Fill out the 'Personal Details' section, including your date, first name, last name, date of birth, address, state, suburb, postcode, phone number, and mobile number.
3. Indicate whether you wish to receive newsletters and information on public lectures by selecting either 'Yes' or 'No'.
4. Select how you heard about NIIM Gold Coast from the provided options, and if you were referred, please specify by whom.
5. Enter your Medicare card number and reference number if applicable, along with details of your current family doctor and their clinic's phone number and address.
6. Provide information for your emergency contact, including their name and contact number.
7. In the 'Previous Health Concerns' section, list any past medications, allergies, previous illnesses, or surgeries.
8. In the 'Current Health Concerns' section, describe your current symptoms or complaints, any investigations you've undergone, and treatments you've received.
9. Complete the 'Diet History' section by detailing your meals, food intolerances, fasting history, appetite, and any medication allergies.
10. Fill out the 'Sleep History' portion, answering questions related to sleep quality, duration, nighttime awakenings, and any sleep aids used.
11. Provide your 'Family History,' including any genetic or familial illnesses and cancer history.
12. Answer the 'Work Life' section about your occupation and any stressors you face.
13. Fill out the 'Exercise History' by describing your activity frequency and types.
14. Explain your relaxation practices in the 'Relaxation' section.
15. In the 'Social History' section, provide information about your living situation, including smoking and alcohol history.
16. Sign and date the form electronically using a forward slash before and after your name to confirm your understanding of the consultation fee and cancellation policy.
17. Save the completed document under your full name and email it back to info@niimgoldcoast.com.au.

Begin filling out your Dr Dominique Wells registration form online to streamline your appointment process.