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Please return the completed forms to the clinic at least one week prior to your initial intake consultation.
Dear Client,
Congratulations on making an important step towards the attainment of long-term vibrant health. As you probably know, the emphasis of my practice is on seeking the underlying causes of poor health rather than focusing on symptom relief.
This means going deeply into your diet, lifestyle and daily routine and assisting you to find the individualised health regime which will help to “switch off” the program which is driving many of your current health challenges.
This approach means that you will be able to take your health into your own hands, and learn how to stay well, track your progress and learn better to work with your own individual make-up.
In order to achieve the best possible outcome, we ask that you please have the following information completed in full and returned to the clinic at least one week prior to your initial consultation:Client Registration Form / Health History Questionnaire
Signed Medical Consent Form / Completed Charts and Checklists
Signed Fees and Charges Form / Health Goals & Readiness Assessment
Copies of any relevant recent medical records from
your main treating practitioner / Copies of any relevant pathology results you may
have had over the last 2-3 years (see below)
Please indicate by checking the box below which labs you have had any relevant pathology with so that we can access these reports on your behalf before your initial consultation:
Queensland Medical Laboratories (QML)
Sullivan & Nicolaides (S&N)
Healthscope Pathology:
Coastal Pathology
Other:
IMPORTANT: The information requested above is required to be provided at least seven working days prior to your intake consultation. Provision of this information is important as it will familiarise Dr Gupta with your health history and issues to be addressed before you arrive, thereby making the most of your consultation time.
PLEASE DO NOT TAKE ANY NUTRITIONAL SUPPLEMENTS FOR TWO MEALS BEFORE YOUR INITIAL CONSULTATION, ENSURE YOUR FINGER NAILS ARE CUT REASONABLY SHORT AND WITHOUT NAIL POLISHI look forward to being of service.
In good health,
Dr Sandeep Gupta
Client Registration Form
Title: Mr Mrs Ms Miss Dr
First Name: Middle Name: Surname:
Date of Birth: Day - Month - Year -
Contact Details
Postal Address:
Suburb: State: Postcode:
Home Phone: Mobile Phone: Work Phone:
Email:
Medicare Card Details
10 Digits: Expiry Date: Month - Year -
Medicare Reference Number: (number to the left of your own name on the card)
Communication Preferences
Phone Email
Would you like to receive our e-newsletter electronically? Yes No
Would you like to receive appointment reminders via SMS? Yes No
Emergency Contact Details
Full Name: Contact Phone Number:
Relationship to You:
Consent
I consent to the use and disclosure of my personal health information by Lotus Holistic Medicine to other practitioners directly or indirectly involved in my medical treatment and care.
*Signature: Date: Day - Month - Year -
*To sign this form electronically please place a backward slash \ at the beginning
and end of your name as follows: \client name\
Medical Consent Form
I, (please insert your full name),
of, (please insert your address)
understand that:
· I am seeking to consult Dr Sandeep Gupta in his capacity as a medical practitioner with a special interest in nutritional and environmental medicine.
· Dr Gupta’s approach involves a longer than standard consultation time and a more holistic approach to patient treatment and care – primarily involving diet, supplementation, exercise, and lifestyle change and stress management.
· Dr Gupta charges a private fee for his consultations, which, in the majority of cases attracts a Medicare rebate. In most cases he does not bulk bill. This is due to the model of care we provide not fitting with bulk billing.
· The majority of diagnostic tests ordered by Dr Gupta do attract a Medicare rebate; however specific functional pathology tests may not attract a rebate. The costs of these tests will be discussed with me by Dr Gupta at the time of ordering.
· Dr Gupta may offer some recommended products for purchase from his clinic directly via Evolutionary Health Solutions, a related business. This is provided as a service and there is no obligation to purchase any products from our clinic or any businesses we recommend. Supplements may be purchased from any retailer of choice.
· Some of the treatment suggestions (e.g. nutritional or digestive supplements) offered by Dr Gupta are considered to be outside the parameters of conventional medicine in Australia. These treatments fall under the category of complementary or alternative medicine.
· These interventions are in the majority of cases supported by research evidence, and are only prescribed with utmost care and within Dr Gupta’s area of training, knowledge and expertise as in integrative medical doctor.
I am attending Dr Gupta’s clinic of my own free will and consent and exercise my right to discuss and choose any suitable treatment options made available to me.
*Signature:
Date: Day - Month - Year -
*To sign this form electronically please place a backward slash \ at the beginningand end of your name as follows: \client name\
Fees and Charges Form – Part 1
Fee Schedule
Dr Gupta charges a private fee for his consultations, which in the majority of cases attracts a Medicare rebate.
SUNSHINE COAST CLINIC· $540.00 for a 1 hour 30 min initial consultation
· $180.00 for a subsequent consultation of 30 mins
· $70.00 minimum consultation charge
· Pro-rata $60.00 per 10 minutes / SYDNEY CLINIC
· $810.00 for a 1 hour 30 min initial consultation
· $270.00 for a subsequent consultation of 30 mins
· $70.00 minimum consultation charge
· Pro-rata $90.00 per 10 minutes
Payment of Fees
All fees are payable at the time of consultation. Payments can be made via cash, EFTPOS and credit card.
Concession Rates
Due to the longer appointment duration Dr Gupta provides concession rates are not available.
Medicare Rebates
At the Sunshine Coast clinic we are able to process your Medicare rebate at the time of consultation. To facilitate this, please bring your Medicare Card and a key card that is attached to a savings or cheque account. Currently, Medicare rebates are unable to be provided at the Sydney clinic - you will be issued with a tax receipt which you will need to take to Medicare to claim your rebate.
Bulk Billing Policy
Lotus Holistic Medicine is not a bulk billing practice. The only exception to this is annual or three monthly care plans which may be bulk billed when Medicare eligibility criteria are met.
Cancellation Policy – New Clients
A deposit of $150.00 is required to secure your new patient intake consultation which is payable at the time of booking your consultation. This deposit can be made over the phone by credit card or directly to the following account:
ACCT NAME: Radiant Life BSB: 064 420 ACCT NO: 1079 6709
Please be sure to use your own name as the payment identification reference.
Please note that 48 hours notice is required if you wish to cancel or reschedule your initial intake consultation.
The deposit amount of $150.00 is non-refundable if less than the specified 48 working hours notice is provided and we are unable to fill your consultation time from our waiting list. If you wish to cancel or reschedule your appointment please do not leave a message on the answering machine or send an email over the weekend – cancellations and rescheduling must be completed during working hours Monday – Friday. Please ensure that you speak with client support staff personally or receive an email confirmation to verify that your request to cancel or reschedule has been received and processed.
Contact details for cancellations and rescheduling:
Phone: (07) 5457 3483 or Email:
We do understand that there are rare occasions when it is not possible to give 48 hours notice to cancel or reschedule your appointment. In these instances, if we are able to fill your appointment from our waiting list, your deposit may be refunded or transferred to your rescheduled consultation time, however a refund is not guaranteed.
If you do not attend your new client intake appointment and do not provide advance notice of your inability to attend a no-show fee of $150.00 is payable.
Please check the box below:
I have read, understand and agree to the new client cancellation policy as outlined above
Fees and Charges Form – Part 2
Cancellation Policy – Existing Clients
If you do not attend your appointment and do not provide advance notice of your inability to attend a no-show fee of $50.00 is payable.
Please check the box below:
I have read, understand and agree to the existing client cancellation policy as outlined above
Appointment Reminders
An SMS appointment reminder service is available – please ensure that you register for this service by checking YES on the Client Registration Form found on page 3 if you would like to be reminded of your consultation in advance. Lotus Holistic Medicine does not take responsibility for SMS reminders not received. It remains the clients’ responsibility to keep track of their appointments and to update their mobile phone number with our reception staff if their contact details change. Please note that the SMS reminder service is a NO REPLY service – which means that you must call us or send an email if you are unable to attend your appointment or need to reschedule.
Email Policy
Generally we are available by email for simple clarifications of aspects of the treatment protocol such as a dosage of a medication or supplement or problem obtaining a particular product or supplement.
We also request clients to notify us of any significant new symptoms that occur while on the holistic medicine program.
When a discussion needs to take place to clarify the exact nature of symptoms and to devise a plan, Dr Gupta may ask for a physical or telephone consultation, as generally it is considered good medical practice to assess a patient thoroughly before suggesting a course of action. Generally this will attract a short consultation fee.
For extensive questions, such as how to tailor your diet exactly to fit the holistic medicine program or significant changes to your program which are requested, Dr Gupta will generally request a phone or email consultation. An extensive email consultation fee is generally $120 which includes responding in depth to several questions generally taking around 20 minutes of Dr Gupta's time.
Results Policy
Generally results will be forwarded from imaging or pathology companies directly to Dr Gupta for review. In general our policy is to contact clients with results only if immediate action is required on the basis of this result, e.g. change in the medication or supplement program, or hospitalisation. It is not our routine practice to send all results to patients. Our preferred practice is for you to request any results you require during a consultation with Dr Gupta. However if not possible, results may be requested by email after they are available and they will be forwarded onto you.
Please check the box below:
I have read and understand the fees and charges as outlined in this document
*Signature:
Date: Day - Month - Year -
*To sign this form electronically please place a backward slash \ at the beginningand end of your name as follows: \client name\
Support on the Health Journey
Clinic Opening HoursSunshine Coast: Tuesday – Thursday from 9.00am – 5.00pm.
Sydney: Once a Fortnight on Friday from 9.00am – 5.00pm.
How to Contact Us
We are very happy to receive any questions, consult bookings and advice of cancellations via email. You can also phone us and if we are busy on another call or the clinic is unattended, please leave a message and we will return your call. We do intermittently monitor emails on weekends, so if you need a response outside of normal clinic hours this is the most efficient way to contact us.
Woombye Clinic: 56 Plantation Rise Drive, Woombye QLD 4559
Sydney Clinic: Fayworth House, Suite 605, 6th Floor, 379 - 383 Pitt Street, Sydney NSW 2000
Postal Address: PO BOX 1113 Buderim QLD 4556
Phone: (07) 5457 3483 Email:
When to Contact Us
Please contact us if you are having any problems related to implementing your treatment program including the diet and any lifestyle changes. Please also contact us if you are unsure of any of your dosages, if you experience any significant deterioration in your condition, or if you have any adverse reaction to any supplement or medication that Dr Gupta has prescribed.
Communication Response Times
We aim to respond to all messages within 24 - 48 hours of receipt during regular clinic hours, however please be aware that messages and requests received are triaged in order of urgency so occasionally longer response times may occur.
Filling Out Forms
If you require a form filled out to receive a benefit or a permit this usually needs to be completed within the context of a consultation – please mention at the time of booking your appointment that you require forms to be completed.
Medical Emergency
As the clinic opening hours are limited to Tuesday – Thursday from 9.00am – 5.00pm, please contact your nearest emergency medical department or phone an ambulance on 000 if a medical emergency should arise.
Maintaining a Regular GP
Due to the emphasis on nutritional and environmental medicine, Dr Gupta suggests maintaining a relationship with a regular GP for routine matters such as immunisations, surgical screening tests and any simple matters that you may prefer to have bulk billed.
Obtaining Medical Results & Reports
We are more than happy to provide email copies of your test results to you when these are required, however we do not routinely supply ‘normal’ test results to patients. If you need your results to be printed out and posted in hard copy this may attract a small fee, depending on the quantity of printing and postage required.
Health History Questionnaire