Patient Wellness Intake Form

We're glad you're here.

This short form helps our clinical team understand your health goals, symptoms, lifestyle and medical background before your appointment. Your answers help us give you safe, supportive care that fits you.

• Takes just a few minutes
• Private. We do not sell your personal information.
• No obligation or credit card

Begin Assessment

By continuing, you consent to the collection and use of your personal and health information in accordance with Elevate For Her’s Privacy Policy and Terms of Use. You also consent to receiving healthcare services via telehealth. Your answers will be reviewed by an AHPRA-registered Australian clinician. Your information is handled securely in accordance with our Privacy Policy and Australian privacy obligations. We do not sell your personal information.

Optional: I would like to receive occasional health updates and news from Elevate For Her by email or SMS. This is separate from consent to care, and declining does not affect your treatment. You can unsubscribe at any time.

Not all consultations result in a prescription. Your clinician may recommend lifestyle changes, monitoring, referral, or no treatment.

This assessment is a data collection form only. It is not a diagnostic tool and does not constitute medical advice. A clinician will contact you to discuss next steps.