Adjunctive Cancer Support Registration

Please note: This is not a program to cure cancer. It is a lifestyle management program aiming to improve the quality of life only. Patient enrolled in this program should not cease any conventional cancer treatment therapy currently undergoing or proposed by their treating specialist, including but not limited to chemotherapy, radiation therapy or any other therapy. Undertaking this program does not alter your prognosis or orthodox management.

Personal Details

Patient's Name(Required)
Please enter your medicare number, followed by your reference number, then expiry date.

Current GP Doctor

*If you are seeking adjunctive cancer treatment, you will need to continue to see your current Medical Practitioners. This could be your local medical centre that you are thinking of attending.

Emergency Contact

Do you have an advanced health directive?
If yes, please provide this to the clinic on your first visit.


Which stage of cancer?
10 being the most pain
10 being the most tired
10 being the least active
(In time order)
(Scans, CT, Biopsies etc. in time order)
(Surgery, Chemotherapy, Radiotherapy and Alternative including Oncologists/Surgeons, treatment outcomes and when completed)
(New Cancer or secondaries)
Health Concerns / Symptoms / Diagnosed Conditions. Please list in time order.
Please list in time order.

Diet History


Sleep History

Family History

History of Chronic or Viral Infections


Exercise History


Social History

Please sign below to confirm that you acknowledge and accept the New Patient Consultation Fee of $560 and confirm the above details are true and accurate. Please also note that our doctors support conventional cancer management and may also refer you to a suitable oncologist if you do not have one. One of our clinical staff members may call you in advance of the consult to discuss regarding our treatment process and follow up to see if you have any queries. Please also note that we require 24 hours’ notice for cancellation of appointments. Failure to do this will result in a charge of 100% of the consultation fee.

This field is for validation purposes and should be left unchanged.