Phytotherapy Consultation Intake Form

Dear Client,

Thank you for giving me the opportunity to support the healing of your health condition and your wellness journey.

We specialize in Phytotherapy for treating the root causes of chronic conditions and work with you to promote holistic health so you can stay vibrant in body, mind and soul.

Please visit for educational information, product knowledge, and online product order.

To learn more about Naturopathy/Phytotherapy and read our clients’ healing stories you may download this pdf

Contact us @ +65-6538 9978 or

I invite you to join our mission and become part of a community of like-minded people and to help others.

Telegram channel for health tips, updates, and healing stories:

Facebook page:


Sign up for our newsletter:

May you be blessed with peace and health.

Sebastian Liew, Doctor of Naturopathy, Medical herbalist

Director, Sebastian Liew Centre Pte Ltd


Full Name*

NRIC/Passport No.*

Date Of Birth*

Time Of Birth

Country of Birth*

Contact/Mobile Number*

Country code followed by contact number, e.g., +6588207661

Contactable By WhatsApp?*

How did you hear about us? (Please include the name of the person who referred you, if applicable)*




What kind of practitioners are you currently under the care of?*

Do you smoke?*

Do you drink alcohol?*

On a special diet such as vegetarian, keto, etc...?

Are you having a flu now, pregnant, or taking contraceptive?*

Marital Status*

No. of children? Normal delivery?

Pharmaceutical Medications / Supplements / Traditional Medicine*


Provoked by?

Better with?

How do you feel about the condition?

The onset of symptoms if any

Severity from 1 - 10 (10 being the worst)

Do you prepare your own meals?

Do you skip breakfast?

How is your breakfast like?

Are you a vegan?

What is your daily regular beverage?

What food do you like to eat every day?

Menstrual related (irregular, spotting, fibroids, PMS menopause etc.)

Digestion (Appetite, Reflux, bloating, constipation etc.)

Heart (blood pressure, cholesterol, circulation etc.)

Nervous related (sleep, anxiety etc)

Skin Condition

Past surgery

Immune (infection, constant flu and cold etc.)



Sleep (Bedtime, onset, wakeful, fatigue)

Do you wish to be in our mailing list?


Sebastian Liew Centre Pte Ltd respects your privacy. We collect your name, contact, health info, and NRIC/passport for diagnosis and (for email subscribers) health education. We may share data with authorities with your consent or as required by law. Your data is secure in the cloud. You have rights to access, correct, and delete your data. Contact us at +65-6538 9978 or to learn more.

Informed Consent

In presenting yourself for Phytotherapy treatment as practiced by Sebastian Liew Centre Pte. Ltd. or consumption of any of our health supplements, you acknowledged and agreed that it is intended to promote health, support healthy functions, and general wellness.

Phytotherapy does not diagnose disease, nor does it prescribe drugs or surgery.

You understand that Phytotherapy is not a substitute for medical treatment or medications, and that it is recommended that you concurrently work with your primary health provider for any medical condition.

All herbal remedies or supplements recommended must not be taken together with any pharmaceutical medications. If in doubt, please seek professional advice.

You voluntarily consent to receiving phytotherapy or consuming our health supplements, and have informed our herbalist of all your known physical conditions, medical conditions, and medications. Furthermore, you will keep your primary health care provider, or the medical doctor, updated on your health condition.


Appointments are only confirmed after the submission of this form.


Please Upgrade Your Browser To Enable Signing Functionalities