New Patient Form - Dr. David Jaa

Step 1 of 4

Patient Name(Required)

Prefix First Last

Preferred Name

Date of Birth:(Required)

Are you seeking adjunctive therapies related to cancer?(Required)

Yes

Go to complete our Cancer Registration form

So that we can best understand your needs, please complete the Cancer Registration form.

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Patient Email Address:(Required)

Patient Phone(Required)

Medicare Number

Please enter your medicare number, followed by your reference number, then expiry date.

Gender(Required)

Male

Female

Other

Are you of Torres Straight and/or Aboriginal Origin?(Required)

Yes

Occupation

Marital Status

Number of Children

Describe Your Current Problem:

Mention your diagnosed conditions and symptoms.

What have you tried:

Mention therapies and treatments.

What are your goals:

What do you hope to achieve by seeing one of the doctors at IMH Gold Coast?

How did you hear about us?

Consent Information

The following consents are for all therapies available at the clinic. These consents are only applicable if you are undertaking these therapies.

General Consent

The staff at IMH Gold Coast may request your previous testing results on behalf of your treating practitioners. These may include, but are not limited to pathology, radiology, and any relevant specialist treatment reports from third party providers.

Some of the accessory functional pathology tests, treatments and products administered by practitioners at IMH Gold Coast may be outside the parameters of conventional medicine in Australia. They include IM (Intramuscular), IV (Intravenous) and PR (Per Rectal) applications.

These tests, treatments and products fall into the category of Natural or Complementary Medicine. These functional tests, treatments and products are supported by empirical knowledge and in many cases by research data.

That these tests, treatments and products are safe, are widely and successfully used by Integrative Medical Practitioners in Centres in Australia and overseas, and are only prescribed with utmost care.

Some functional pathology tests and treatments offered at IMH Gold Coast are not covered by Medicare or private health insurance funds.

All IMH Gold Coast practitioners are members and active participants of their respective professional colleges.

I also understand that practitioners benefit either directly or indirectly from tests recommended at this practice.

I am attending IMH Gold Coast of my own free will and consent and exercise my right to discuss and choose any useful and suitable treatment(s) made available to me. Information obtained at the clinic can and may be used de-identified for research and publication.

I understand that there will be private fees applicable that are not rebatable by medicare or insurance for my consultation, supplements or treatments. Consultation fees will be clearly specified to me by my doctor prior to treatment.

I am signing to confirm that I have understood the conditions as set out above and have been made aware of the associated risks with regards to data protection.

Musculoskeletal Medicine

Musculoskeletal medicine is highly specialised discipline of medicine, covering a wide range of skills and techniques. These techniques at times will involve you to have:

Needles (acupuncture and hypodermic) inserted into your body.
The substances injected can be autologously derived, vitamin and mineral and oxygen based.
Specific body positions and postures with detailed examination.
Undressed down to underwear.
Performed prescription exercises twice daily for 4 to 5 repetitions.
To join a group of 2 to 3 people in 1 class.
At times there may be a need for close physical contact between yourself and the Doctor.

Musculoskeletal Medicine has relatively few complications in skilled hands though there is a chance of feeling sore or worse for up to 2-3 days. This is normal. It is extremely rare for a fracture or a collapsed lung (pneumothorax) to develop due to the medical therapy. It is also rare for any type of infection or neurological complication to develop from the procedure.

If you have any hesitation about the above information, please discuss with us your concerns. Cervical Manipulations are rarely carried out in this practice. If this is necessary it will be further discussed with you and a special test will be carried out to see if this is possible to perform on you. Information obtained at the clinic can and may be used de-identified for research and publication.

Treatments

Doctors may recommend that I receive treatments such as intravenous and/or intramuscular Supplement injections. Treatments recommended may include but not limited to PRP, Botox, Fillers, Glucose or Vitamin injections, epidurals, nerve blocks, progenitor cells, excisions of tissues, intravenous infusions and intramuscular injections.

I understand:

That these treatments may be outside the parameters of conventional medicine in Australia.
That these treatments are supported by empirical knowledge and by research data
That these treatments are widely and successfully used by integrative medical practitioners in centres in Australia and overseas, and are only prescribed and administered with utmost care.
That these treatments are not covered by Medicare and may not be covered by private health insurance funds.
That these treatments may not be regulated by the Therapeutic Goods Administration (TGA) and that the IMH doctor deems that these treatments are in my best interest.
Also that the IMH doctor has made me fully aware of any risks associated with these treatments and has provided me with sufficient information to make an informed decision.

Possible Side Effects

Local anaesthetic complications: nerve damage, nausea, vomiting, disorientation, fitting, loss of blood pressure, high blood pressure, coma, death.
At times you will not be able to drive home post procedure
Intramuscular iron injections may cause permanent brown discolouration of the skin
Extreme allergy from any substance or object penetrating the skin, resulting in itch, hives, asthma, and even death.

The following symptoms can be inclusive but not exclusive to:

Haemolysis for patients with G6PD deficiency if high dosage given
Headaches
Nausea
Vomiting
Trembling
Fatigue
Mild Dehydration
Local irritation of veins (eliminated by flushing at end of IV)
Chest pain
Shortness of breath or other breathing issues
Tightness in the throat and chest
Allergic reaction-type symptoms (breaking out into hives, rashes, swelling up, or excessive itchiness)
Magnesium and Vitamin C caution in patients with kidney problems
Heart block
Low blood pressure
Confusion
Upset stomach
Hypotension
Diarrhoea
Increased Amylase
Pregnancy lactation considerations (ALA0)
Interaction with medications
Skin irritation
Hypoglycaemia

I am agreeing to the prescribed treatment(s) of my own free will and consent and exercise my right to discuss and choose any treatment(s) made available to me.

I also understand the results of these treatments vary between individuals.

Nutrients, Supplements and Other Substances

Some, or all of the nutrients could be at much higher dosages than that which is specified by the recommended daily intakes by NHMRC (National Health and Medical Research Council).

It is important that I take these prescribed supplements as directed by my doctor.

I will return for review of my health at date which is specified by my doctor.

If I fail to attend these reviews then I will no longer take any of the supplements prescribed to me by doctor after the specified review date.

I understand that these supplements are only prescribed for me and are not to be used for anyone else.

I understand that prolonged taking of certain supplements at high dosage without medical supervision could lead to adverse health outcomes such as nerve and thyroid disorders. I will direct any question of concerns to my Doctor during my consultations.

Some of the products are not TGA listed and may need a SAS (Special Access Scheme) form to be submitted on my behalf.

I understand that taking high doses of B6, iodine, lithium, selenium, molybdenum and other vitamins and supplements prescribed by the doctors need to be monitored. Side effects may include, but are not limited to:

Tingling in hands, feet and tongue
Metallic tastes in the mouth
Undue fatigue or agitation or mood swings
Worsening of your condition
Excessive nausea

I will stop taking these supplements if I notice any of the above and will notify my doctor immediately.

Will your treatment include a Work Care Plan(Required)

Yes

Fees & Charges

Please sign below to confirm that you acknowledge and accept that initial consultation is $620.00 for an hour. Follow-up consultations are 45 minutes for $465.00 (any extension will be charged $155 per 15 minutes). In the consultation Dr Jaa will take a comprehensive history, there may be other surgery-based testing (these may incur a charge) and a referral for pathology tests. (A larger rebate may apply if you are over the Medicare Safety Net). Please also note that we require 24 hours' notice for cancellation or rescheduling of appointments.

Dr David Jaa-Kwee's medical fees are as follows:

There is an Hourly rate for the type of services rendered including but not limited to time spent on phone calls, email and treatment. If your condition is complex and involved, the higher rate may apply. The fee includes non-face-to-face time for research and documentation in the medical record.
15-minute increments is the fee base, and the time is rounded up to next 15 minute increment. So, the charge will be based upon 15, 30, 45, 60 minute allocations.
Additional costs of “consumables” are added for the medical service. eg injections / application of machines/bandages/admin in arranging time for the medical services faxes and emails. These typically are 25 dollars to 75 dollars.
Script request fees may also apply.
The medical service includes the time assistant nurses/ staff spent in the consultation process.
Medicare rebates generally apply but the not all services are Medicare rebatable.
The hourly fee if $620.
The doctor in individual case may elect to lower fees.

Cancellation fees may apply if 24hrs notice is not given.

By signing below, I acknowledge that I have read and understood the above information and confirm that the details supplied are true and accurate to my knowledge.

Signature(Required)

CAPTCHA

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

Formerly NIIM Gold Coast

New Patient Form - Dr. David Jaa

Go to complete our Cancer Registration form

Previous Health Concerns

Current Health Concerns

Diet History

Sleep History

Family History

History of Chronic or Viral Infections

Stressors

Exercise History

Relaxation

Social History

Fees & Charges

New Patient Form - Dr. David Jaa

Go to complete our Cancer Registration form

Previous Health Concerns

Current Health Concerns

Diet History

Sleep History

Family History

History of Chronic or Viral Infections

Stressors

Exercise History

Relaxation

Social History

Consent Information

General Consent

Musculoskeletal Medicine

Treatments

Nutrients, Supplements and Other Substances

WHSO Consent Information

Fees & Charges