Wellness Clinic Intake Form

Welcome to The Church Of Ubuntu Wellness Clinic

First, please complete our wellness intake form below, with as much information as possible. If you or your carer are unable to complete this form for either health reasons, or internet limitations, please email info@churchofubuntu.org

* Administration Costs – $50. Once your wellness form is received and entered into our system our consultants read all your case particulars and create a comprehensive program for you including, diet, health, lifestyle, natural medicine recommendations and where to purchase medicines. You will then receive a personal phone call (and email) from one of our assistants, containing all of this information and how you can proceed. (first contact generally takes about 7 to 14 days from intake form receipt, assessment within 21 days pending our workload, with apologies). If you have any questions about the time and process please either email us at: info@churchofubuntu.org.

Please ensure clients name is on your payment.

Terms and conditions refund and returns policy


*This form needs to be completed from a personal computer and not a hand-held device
*Please ensure ALL answer fields are filled in, where a question is not relevant please type N/A
*Please also correct any error messages prior to resubmitting
*Please regularly check your 'junk box', or similar, for emails from us


The Church of Ubuntu is supported by many members of the community, we are a not for profit incorporated association. Our health consultants are all highly experienced and each one can offer a great insight into your health and well-being . The first step to wellness is to accept full responsibility for ones own health, we offer a much needed alternative to allopathic medicines, we aim to cure occasionally, relieve often, and comfort always. The Ubuntu Team.

Intake Form