Mohsin Health Clinic: Patient Intake Form
This intake form is for those wishing to book any of the following appointment types:
-- Consultation STANDARD (Up to 30mins) £95
-- Consultation CONCESSIONARY (Up to 30mins) £75
(Concessionary rate ONLY for under 16s, 65+, and CoMHA students.)
1-Year Support Packages:
-- First Consultation STANDARD + 1-Year Support (4 x 30-min Follow-Ups) £295
-- First Consultation CONCESSIONARY + 1-Year Support (4 x 30-min Follow-Ups) £235
-- Iridology Report + Consultation + 1-Year Support (4 x 30-min Follow-Ups) £395
-- Counselling Session + 1-Year Support (4 Quarterly 45-min Follow-Ups) £995
Current availability for M Salim Khan: Saturday 6th and Wednesday 10th June 2020.
Please take about 20mins-30mins to fill out this form. Then, you will be able to schedule your appointment. All questions are to be answered by the patient (or on behalf of the patient by a family member / trusted carer.)
Important: Before filling out this form, please make sure that 1) You have all your existing medicines and supplements on-hand, and 2) That you have kept a 3-day food diary of everything you eat and drink and what times for 3 consecutive days. You will need to provide this information on this form.
(Alternatively, if you prefer to fill out the forms by hand, or in your word processor, you can download these at
The information that you give us on this form is necessary for your practitioner to make a full assessment of your health and wellbeing, and will contribute to informing the treatment plan that is put together for you.
CONFIDENTIALITY NOTICE: ALL PATIENT DATA IS HELD AS STRICTLY CONFIDENTIAL BY MOHSIN HEALTH, 446 EAST PARK ROAD, LEICESTER, LE5 5HH, UNITED KINGDOM, REGISTERED AS A LIMITED COMPANY IN ENGLAND & WALES #06461476. WE DO NOT SHARE YOUR INFORMATION.
Page 1 of 8
Never submit passwords through Google Forms.
This form was created inside of Mohsin Health.