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Your One-Stop Health Shop. Call us on: 07 573 5489

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Consultation Form

Wanting to Detox safely and easily with minimal disruption to your current lifestyle?

- Do you have weight issues?
- Are you experiencing bloating, reflux or constipation?
- Feeling mid-afternoon brain fog?
- Have you an ongoing health issue that needs further support?
- Unsure which supplement or herbal to take?

Perhaps a consultation with Debs would suit your needs. Debs Chase-Paterson as been a practising Natural Medicine Practioner in her own clinic for over 20 years.

Fill in our Online Consultation Form below to get started

    Page 1 of 2

  1. Name*
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  2. Date of Birth
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  3. Address*
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  4. Phone*
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  5. Email*
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  6. Occupation
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  7. How did you find/hear about us?
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  8. Medical History











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  9. Other Medical History
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  10. Childhood illnesses
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  11. Past Health Issues (Include Operations)
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  12. Family Health History
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  13. Present Health issues or reasons for consultation
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  14.  

    Page 2 of 2

  1. Do you have inflammation/fever/infection at present?
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  2. Are you having other therapies at the moment & if so what are they?
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  3. What other therapies do you currently have?
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  4. Have you been exposed to excess heavy metals/chemical sprays/toxins/drugs ?
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  5. What was the exposure?
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  6. Further information we may need to be aware of
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  7. Medications/Supplements
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  8. Stress gauge
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  9. Sleep patterns
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  10. Bowel Motions
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  11. Lifestyle
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  12. Diet












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  13. Other Diet
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  14. Fluid intake










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  15. Other Fluids
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  16. Takeaways/Desserts:




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  17. Cravings



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  18. This consultation is based on recommendations given to the best of my abilities and based on training and clinical experience as a Registered NZ Natural Medicine Practitioner & Body Worker (qualified under various modalities) for over 20 years. All information obtained during this consultation will remain confidential. I confirm that under no circumstances can I be held responsible for any claims or damages accrued from any action carried out following this consultation, Should you have queries regarding this, please contact Debs.
  19. I have read and agree to the above disclaimer*
    You must agree to above disclaimer
  20. *
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  21. One Online Consultation
  22. Total to pay:
    0.00 NZD

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Contact Us

Kiwikitz Ltd

28 Jellicoe St
Te Puke 3119
BOP
New Zealand
Phone: +64 07 573 5489
Fax:  +64 07 573 9363
sales@kiwikitz.com