Patient Introduction

(please read carefully before completing)

We ask you to fill this out for either consultation or examination purposes. Examinations are done

routinely to determine the nature and extent of your condition. The practitioner will explain the level

of examination which is necessary for your type of condition.

More detailed or specific examinations may be needed in

complex or chronic cases to make confirmation.

Full Name

Date

Phone

Fax

Email:

Complaints or existing condition

Complaints secondary to these

Current or previous primary care doctor's name, specialty, phone number

What type of service do you desire:

Temporary relief of symptoms/pain control.

Attention to removal of the tendencies causing your condition.

Balanced optimum health care: Elimination of root/cause of problem, if possible.

Maintenance care: regular balancing or "tune-ups" to keep in good health.

Seasonal Tune-ups: such as prior to allergy season or cold and flu season.

How would you classify your condition:

Minor.

Moderate.

Involved.

Fairly severe and progressively getting worse.

Serious.

This is not a detailed history. Please circle all of the below conditions if the answer is "yes":

| Tendency to faint | bruise or discolor easily | bleed for a long time | have hepatitis | have AIDS |

have high blood pressure | any heart problems | any respiratory problems or received similar

services | taking any other therapies at the same time | had surgery before | taking any medication

| are hungry at the present time | exhausted at the present time | nervous at the present time |

Consent for Service: I, the undersigned, am aware of both the benefits and risks of this service

and give my consent for care. I fully understand that there is not implied or stated guarantee of

success of effectiveness of a specific procedure or modality or services as such. I further realize

that our service may not be covered at this time by Medicare.

Patient/Client's Signature

Print Name

Date

Signature of Guardian

Print Name

Date

IT IS AGREED: The ATTENDING PRACTITIONER will provide health care and other services to the

patient /client, to the best of his/her skill and knowledge, in the light of circumstance and what is

possible and practical. The patient/client will cooperate fully with the practitioner by following his/her

instructions and adhering to such treatment plan or course of action as may be set forth and agreed.

IT IS ALSO AGREED: I agree to hold harmless this practitioner or to present any issue or concern

of medical malpractice by letter to the practitioner. If taken further, action will be decided by neutral

arbitration, and therewith, I forego my right to jury or court trial should an issue arise. Because of

the differences in human constitution and response, I understand that no practitioner can legally

warrant the outcome of their medical care and service.

Patient

Client Signature

Date

Authorization to Release Information: I hereby authorize any physician, surgeon, practitioner,

registered pharmacist or other person, any hospital, any medical service organization, any insurance

company or any other institution or organization to release to you and you to them any medical

or other information acquired concerning my condition or other disabilities. A photostat of this

authorization shall be valid as the original.

Patient

Client Signature

Date

I clearly understand and agree that all services rendered me are charged directly to me and that I am

personally responsible for payment. I also understand that if I suspend or terminate my care and

treatmentand fees for professional services rendered me will be immediately due and payable.

Person responsible for the account?

Method of Payment:

Cash

Paypal

The above statements by me are accurate to the best of my ability.

Patient

Client Signature

Date

Guardian or Spouse's Signature authorizing care

Date

Please complete all blank spaces and signatures and give this to the receptionist.

We welcome you to our office.