Mark Pillans

    Patient forms

    If you intend to email me sensitive data, I recommend you consider setting up a Protonmail email account (free via https://protonmail.com), which will keep your information securely encrypted and only accessible between ourselves. My email – but not the contact form via this site – runs through Protonmail. You can email me from any email system, but non-Protonmail accounts will not be encrypted.

    Health questionnaire:

    PDF version

    Intake form – health questionnaireDownload

    Word document version

    Intake form – health questionnaireDownload

    Online form

    The following form is powered by Cognito Forms and complies with international regulations such as GDPR, HIPAA and CCPA, and meet ADA standards for online accessibility.

    Online health questionnaire

    Treatment consent forms:

    PDF files

    Consent form – adult herbal medicine treatmentDownload
    Consent form – child herbal treatmentDownload

    Privacy/ GDPR consent forms:

    PDF files

    Consent form – privacy- GDPRDownload
    Consent form – Heidi (+ explainer)Download
    Book online
    Contact me