Patient Forms

Thank you so much for choosing us for your Healthcare needs. We are always glad to make appointments for you, and we appreciate your interest in Integrative Medicine.

We request that cancellations be made at least 24 hours in advance of your appointment. Our policy is to charge you the cost of the appointment if your appointment is missed or cancelled with less than 24 hours notice. This charge will be due before the next scheduled appointment.

A late cancellation prevents us from offering this time to someone in need. If the office is not open, you may always leave a message requesting a cancellation or rescheduling… we thank you for your understanding.

We are considered non-participating and non-filing with insurances.

 

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The following forms are available in two formats: Microsoft Word or Adobe PDF.

To view and print a form, click on the corresponding icon below and the page will open a new browser window.

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Please Note:

For your first visit with a physician, please fill out the Adult Medical Questionnaire or the Pediatric Patient Form and the Record Release Form.  Please also read the Patient Privacy Notice and print and sign the first page only.

For your first Holistic Health and Nutritional Counseling Appointment with Beth, please fill out the Women’s or Men’s Confidential Health History form.

For your FirstLine Therapy Appointment, please read the BIA Patient Brochure, FLT Appt Letter and follow the prep instructions beginning 24 hours before your appointment.  Please also fill out the FLT Health History and Health Profile Questionnaire and if time permits, the Diet Diary and Exercise Log.

Adult Medical Questionnaire	MS Word
Records Release Form	MS Word	Adobe PDF
Privacy Notice	MS Word	Adobe PDF
Women's Confidential Health History (NUTRITION VISITS ONLY)	MS Word	Adobe PDF
Men's Confidential Health History (NUTRITION VISITS ONLY)	MS Word	Adobe PDF
Pediatric Patient Form	MS Word	Adobe PDF
Revisit Form (NUTRITION VISITS ONLY)	MS Word	Adobe PDF
BIA Patient Brochure	MS Word	Adobe PDF
Diet Diary and Exercise Log		Adobe PDF
FLT Apt Letter	MS Word	Adobe PDF
FLT Health History		Adobe PDF
FLT Health Profile Questionnaire	MS Excel
Identi-T Stress Assessment Electronic	MS Excel
Detoxification Questionnaire		Adobe PDF

Medical Info Disclosure

MS Word