Stellar: New Patient Application

Your Name*

First NameLast Name

DOB*

Date

Email*

example@example.com

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What condition or symptoms would you like to be seen for?*

List any prescriptions drugs you currently taking.*

Have you ever been treated by: (check all that apply)*

NaturopathChiropractorAcupuncturistNone of the above

Do you currently have a Primary Care Physician?*

YesNo

Any known food allergies or intolerances?

Are you currently vegetarian or vegan?*

YesNo

Are you a current cigarette smoker?*

YesNo

How willing are you to make diet and/or lifestyle changes to improve your health? (choose one)*

	1	2	3	4	5	6	7	8	9	10

1 is Not Willing, 10 is Completely Willing

Rate your overall health (choose one)*

Are you familiar with muscle testing or Nutrition Response Testing?*

YesNo

Stellar Health and Wellness believes in medical freedom. Knowing this, do you feel we are the best place for you to receive care?

YesNo

How did you hear about Stellar Health and Wellness? (If referred by a friend please give name)*

I am requesting an appointment with

Dr. Della Parker, NDDr. Mollie Walker, NDFirst available

Due to a high volume of new patients and limited appointment slots, we require a $100 deposit for all New Patient visits. This amount will only be charged to your card after you have been accepted as a new patient and your first visit has been scheduled. The full amount will go toward the total cost of your first visit and is non refundable. Please provide at least 48-hour notice if you need to reschedule your appointment. If proper notice is not given or visit is missed without notice the deposit will NOT be reimbursed. If you wish to make a New Patient appointment in the future, an additional non-refundable $100 will be charged to hold that visit as well. Payment will be collected upon scheduling. Thank you for valuing the time we set aside for quality patient care.

Confirm Your Understanding*

I have read and agree to the above terms.

Name on Credit Card*

First NameLast Name

Billing Zip Code*