Patient Forms

Fees
Please contact our office to review fees and cost of care.

New Patient Deposit

A non-refundable $150 deposit is required to hold your new patient appointment. Your deposit will be  applied to the cost of your new visit. Payment is accepted by check, cash or credit card.

If your appointment is  cancelled for any reason  your non-refundable deposit can be applied to a new appointment provided it is rescheduled within 3 months of the original appointment date.

New Patient Intake Form – required for all new visits

There is nothing like hearing about you from you, in person. This will happen during your visit with your physician. However, when we have  familiarity with you before your visit then we can make the most of our time together.

As part of our service, we offer an in online intake form through Living Matrix.  This intake form is required on all new patients.  It is in depth and  specially designed for functional integrative medicine.

Once you make your appointment and have made your deposit, we will send you a link to our online intake form. Filling out the form can take up to 2 hours so please plan accordingly.  Do your best to fill it out as thoroughly and honestly as you can.

Your physician prepares for your visit. In order for this to happen, we need to receive your completed intake form in advance so your physician can review it.  Consequently, if your  intake form is not filled out and received by our office within 72 hours prior to your appointment, your visit will automatically be cancelled and deposit forfeited unless you reschedule within the next 3 months.

Thank – you for taking the time to do  and participating in your care in this way.  If you run into difficulty or have questions, please contact the office.

IMPORTANT: Please use the most updated version of Safari or Chrome when you complete the online Intake Form.  Click here to download Chrome (For PC’s or Macs) or Safari.  (For Macs)

Care Agreements – required for all patients

Establishing clear agreements is an important part of having a healthy relationship. Please fill out and bring to your first appointment. If you have Medicare in any form, please be sure  to fill out the Medicare Opt-Out section. Questions or clarifications can be discussed with our front office staff.

Medical Records Request – recommended if pertinent

Reviewing your medical records, helps us make the most of your initial intake. Medical records will be reviewed if they are received in advance. Please make arrangements using the medical records release form. Fax or send the form to any relevant care providers that you are currently seeing and/or from the past five years.

 

Established Patients – recommended for all follow up visits Download, print, fill out and bring to your visit.

 

Medications, Supplements and Herbs – required for all visits
Please remember to bring in the bottles of all medications, supplements and herbs that you are currently taking to your initial appointment.