Amberfield Medical – New Patient Intake

Welcome to Amberfield Medical. This form helps us understand your health, goals and treatment preferences before your consultation. Please complete it as accurately as possible.

1

Your Details

Full name *

Date of birth *

Cell number *

Email address

Occupation

Emergency contact

2

What brings you in today?

Select all areas you would like to discuss.

3

Medical History

Tick all that apply.

Details of any conditions, hospitalisations or surgeries

4

Current Symptoms

Tick all that apply.

Anything else important for your clinician to know

5

Medications, Supplements & Allergies

List up to 4 current medications or supplements.

Medication 1

Name

Dose

Frequency

Reason

Medication 2

Name

Dose

Frequency

Reason

Medication 3

Name

Dose

Frequency

Reason

Medication 4

Name

Dose

Frequency

Reason

Current medication types — tick all that apply.

Allergies or reactions

6

Lifestyle & Longevity Snapshot

Sleep quality

Poor Fair Good Excellent

Exercise frequency

Never 1–2/wk 3–4/wk 5+/wk

Stress level

Low Moderate High Severe

Smoking / vaping

No Ex-smoker Smoker Vape

7

Aesthetic & Skin Treatment History

Tick all previous treatments.

Last treatment & any complications

Skin notes — tick any that apply.

Skincare routine & main skin concerns

8

Hormone, Weight & Metabolic Health

Current weight

kg

Height

cm

Waist circumference

cm

Goal weight

kg

Hormone, menstrual, menopause, sexual health or fertility details

9

Regenerative & Longevity Medicine

Areas of interest — tick all that apply.

Previous use of peptides, NAD+, exosomes, hormones or other regenerative therapies

10

Safety Check

Tick anything that applies right now.

Details if any are selected

11

Expectations & Consent

What are you hoping to achieve? Tick all that apply.

Subtle, natural-looking results Noticeable but refined improvement Focused on prevention Full optimisation plan Willing to do blood tests Willing to make lifestyle changes

Patient Declaration

I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that withholding medical information may increase the risk of complications or inappropriate treatment. I understand that treatment recommendations will be based on medical history, examination, clinical judgement and, where appropriate, further investigations.

Patient name *

Signature *

Draw your signature using your finger or stylus.

✍️ Draw here to sign

Date

New Patient Intake

Form submitted