The Nyerongsha Institute

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Patient Forms

If you are a new or ongoing patient of Dr. Dickey Nyerongsha, please feel free to download any of these PDF files for your personal use. Some are only required for your first visit.  Others might be needed again from time to time, depending on Dr. Nyerongsha's instructions. 

New Patients

Please complete the following forms and take them to your first appointment:

• Pre-Consultation Instructions
• Symptoms Checklist
• Medical History
• ​Informed Consent

Ongoing Patients

Patients who see Dr. Nyerongsha regularly might need this form:

• Herb Refill Request

General Information

Use this information while continuing your personalized patient care plan:​​

• Moon Chart 2019