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  • NEW PATIENT FORM

  • Dr. Justin Marchegiani D.C.
    Dear Patient,
    Welcome, and thank you for choosing Dr. Justin to support you on your wellness journey.
    WHAT TO EXPECT:
    Please click the "Save" button below before you begin in case you cannot complete the form in one sitting. Please take no more than 30 minutes to complete this form. Any additional details can be addressed during your new patient consultation.
    This is a general overview of care at our clinic. Dr. Justin treats every patient as an individual, and all recommendations are personalized to your health history, symptoms, goals, and clinical presentation.
    STEP 1:
    During your initial consultation, Dr. Justin will review your health history and recommend any appropriate lab tests. Initial supplement recommendations may also be made based on your history, symptoms, intake forms, and clinical assessment. Lab testing is then used to further refine your plan at future follow-ups.
    STEP 2:
    Once lab testing is complete, Dr. Justin will review the results with you during a follow-up consultation and create a personalized wellness plan, which may include diet, supplements, exercise, lifestyle, and stress management recommendations.
    STEP 3:
    Follow-up consultations are used to monitor your progress and adjust your plan as needed. If you have questions during your care, you are welcome to contact the office by email. We look forward to supporting you in reaching your wellness goals and maintaining your health long term.
    Sending Your Labs:
    Please email your labs to office@justinhealth.com with the subject line: Labs for "Patient's Full Name."
    Please name each file using the date, your name, and the type of test. Example: 5-5-17 John Smith blood test.
    This helps us review your labs more efficiently before your consultation.
    In Health,
    Dr. Justin and the Wellness Team!
  • NEW PATIENT FORM

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  • How did you hear off Dr. J and Just In Health?
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  • Spouse Information

  • Please answer all questions frankly, to the best of your knowledge. All information is confidential.

  • Do you presently have any of these G.I. or digestive symptoms? (check)

  • Do you presently have any of these respiratory symptoms? (check)

  • Do you presently have any of these ears, eyes, nose and throat symptoms? (check)

  • Do you presently have any of these endocrine or hormone related symptoms? (check)

  • Do you presently have any of these neurological related symptoms? (check)

  • Do you presently have any of these cardiovascular related symptoms? (check)

  • Do you presently have any of these reproductive related symptoms? (check)

  • Do you presently have any of these urinary related symptoms? (check)

  • Do you presently have any of these musculo-skeletal related symptoms? (check)

  • Do you presently have any of these skin, hair and nail related symptoms? (check)

  • Do you have a history of an eating disorder: Anorexia, bulimia or very low calorie dieting?
  • Metabolic Assessment Form

  • Please circle the appropriate number on all questions below, 0 as the least or never to 3 as the most or always.

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  • Just In Health Policies & Procedures

  • Fee Schedule

    New Patient Consultation with Dr. J: $399 (average 45–60 minutes)

    Follow-up 45–60 minutes: $299

    Follow-up 30–45 minutes: $225

    Follow-up 1–30 minutes: $150

    Payment is due at the time of consultation. Accepted payment methods include electronic money transfer, Visa, MasterCard, Discover, debit cards, HSA, and FSA cards. Payment information is processed and stored through secure payment systems as applicable to ensure payment for services rendered.

    Billing Details

    Consultations are billed based on the actual time used, not the time block scheduled. Many patients underestimate how long it takes to address all concerns, and Dr. Justin prioritizes clinical care over watching the clock. Please choose your appointment length accordingly. New patient consultations may run longer depending on case complexity.

    Late Fee Policy

    Late fees are added automatically, but if you notify us within the first two business days that you need to adjust an invoice, no late fees will be charged. If you need to delay payment for supplements or labs (consults excluded), we can split items into separate invoices to pay later. Orders ship once payment is received. This policy helps ensure timely payment, keeps care moving forward, and prevents delays caused by unpaid or postponed invoices.

    Appointments

    All appointments, including new bookings, follow-ups, cancellations, and rescheduling, are managed through our online scheduling system powered by Fullslate. Need help? Visit justinhealth.com/reschedule for step-by-step instructions on how to book, modify, or cancel your appointment. If it is not done through Fullslate, it is not confirmed.

    Follow-up visits may be booked in 30-, 45-, or 60-minute time blocks. We recommend scheduling appointments 4 weeks in advance. Appointment reminders are emailed 3–7 days prior as a courtesy.

    6-Month Consultation Policy

    If more than 6 months have passed since your last visit, a new patient consult may be required. Longer gaps require additional evaluation to review changes, reassess your case, and update your protocol. Final determination is based on Dr. Justin's clinical judgment and case complexity.

    All scheduling and consultation policies may change and will be reflected in the most current Terms of Service and New Patient Forms.

    Lab Tests

    Lab results typically reach Dr. Justin 2–4 weeks after samples are mailed. You will be contacted to schedule a follow-up if one is not already scheduled. Insurance may cover certain blood tests depending on your plan and deductible; cash pricing is available when insurance is not an option. Patients are responsible for any lab fees not covered by insurance.

    Lab results will not be released until all outstanding balances are paid in full and a follow-up consult with Dr. J has been completed.

    Some patients may have multiple labs to review during their new patient consult. Dr. J can typically review 1–3 shorter lab tests during that visit. If additional pre-visit review is required, a lab interpretation fee of $100–$300 may be applied based on the number of pages.

    Lab Results Policy

    Lab results are released the day before your scheduled lab review consult, upon request. This helps ensure your results are reviewed with the proper clinical context and that you receive Dr. J's full interpretation, guidance, and personalized next steps.

    Lab values alone can be confusing or easily misinterpreted without understanding your symptoms, history, prior findings, and response to care. The true value of testing comes from reviewing the results with Dr. J and using them to update your plan appropriately.

    Please note that specialty functional lab reference ranges may differ from standard conventional ranges and are interpreted in the context of your full clinical picture, not in isolation. Some specialty tests such as DUTCH hormone panels, comprehensive stool analysis, and organic acids testing may be considered investigational or non-standard by conventional medicine.

    Supplement recommendations are based on the patient's full clinical picture, including symptoms, health history, lab results, current protocol, goals, and response to care. Because these factors can change over time, supplement plans are best reviewed and adjusted during the consultation.

    Supplement Use

    Dr. J uses only the safest, cleanest, and most hypoallergenic supplement options available. While reactions are uncommon, sensitive individuals may still experience temporary digestive changes, skin reactions, fatigue, mood shifts, or other symptoms.

    All supplements must be introduced one at a time, increasing gradually as outlined in our Supplement Reaction Guide at justinhealth.com/reaction. If a new or concerning symptom occurs, discontinue the most recently introduced supplement and notify our office.

    Nutritional supplements are used at my discretion as part of a functional medicine wellness program. To the fullest extent permitted by law, I assume responsibility for monitoring my response. Just In Health Wellness Clinic, Dr. Justin Marchegiani, and clinic staff are not liable for individual supplement reactions or sensitivities.

    Cancellation Policy & Online Scheduling

    All cancellations and rescheduling must be completed through our online scheduling system powered by Fullslate. For step-by-step instructions visit justinhealth.com/reschedule. Emailing, calling, texting, or leaving a voicemail does not cancel or reschedule your appointment. If it is not completed through Fullslate, it is not confirmed.

    If Fullslate will not let you reschedule or cancel: You are inside the 3-business-day cancellation window. The system is designed to automatically lock out changes once that window has passed. This is not a technical error. At that point the full consult fee applies if you cannot attend.

    Booking a new appointment does not cancel your existing one. If you book a new appointment without canceling or modifying your current one, both appointments remain active and both are your responsibility. To move an appointment you must either modify the existing one to shift it to the new time, or cancel it first and then schedule a new one.

    To avoid a late cancellation fee, all changes must be completed at least 3 business days before your appointment. Business days exclude weekends and federal holidays. Late cancellations and no-shows are billed at the full scheduled consult value. Requests are timestamped by the portal, not by when you emailed or called.

    Reminder Emails

    Reminder emails are sent when you book and again before your appointment, but due to spam filters, they are not guaranteed. Not receiving a reminder does not waive the missed consult fee. Patients are responsible for tracking their appointment time.

    Time Zone

    All appointments are scheduled in Central Time (CT). Please convert to your local time zone if needed.

    If the Doctor Is Running Late

    Dr. Justin may run 15–20 minutes behind when a patient requires additional support. This ensures each person receives thorough, unrushed care, including you. Please remain available for the entire scheduled consult window. Your visit will begin as soon as the doctor finishes with the prior patient. If you are unavailable when he calls or cannot be reached, the appointment will be considered a missed consult, and the full missed consult fee will apply.

    Super-Bills

    All checkout receipts include CPT and ICD-10 codes for potential insurance reimbursement. For claim instructions, contact the customer service number on your insurance card. The doctor and clinic are not responsible for insurance claims that are denied, delayed, or unreimbursed.

    Super-bill adjustments carry a $5 administrative fee per receipt. Any detailed paperwork requiring the doctor's completion is billed at his standard hourly rate.

    Refunds & Returns

    All sales are final. There are no refunds or exchanges for any lab tests, supplements, consultation fees, or services rendered once provided or delivered. Patients must review all product ingredients on our online store and confirm there are no allergens or sensitivities before ordering. We do not replace or refund packages marked delivered by the carrier. For packages lost in transit (not marked delivered), claims must be filed directly with USPS or the shipping carrier. Any fraudulent chargebacks will be disputed and may be referred to collections if necessary.

    Scope of Care, Informed Consent & Practice Boundaries

    Dr. Justin Marchegiani is not a medical doctor and does not hold a medical license. Services are provided exclusively as functional wellness consultation. Dr. Justin does not diagnose or treat medical emergencies, does not prescribe medication, and does not provide medical treatment of any kind. For emergencies, call 911 or contact your primary care physician. For prescription refills, contact your prescribing physician. All wellness consultations are provided by phone or video. Services provided through Just In Health do not constitute medical diagnosis, treatment, or prescription, and are not subject to oversight by the Texas Medical Board (TMB). I understand I am responsible for maintaining an ongoing relationship with a primary care provider for all medical concerns, in-person exams, and medical evaluations.

    Functional medicine is a wellness-focused discipline that explores factors that may contribute to imbalances in physical, chemical, and emotional stress and how those factors relate to chronic health concerns. Services provided by Dr. Justin Marchegiani are intended to support overall wellness and do not constitute medical diagnosis, treatment, or prescription. They do not replace the care of a licensed physician, specialist, or other healthcare provider. Functional medicine recommendations, protocols, dietary guidance, and supplement plans are educational and supportive in nature, based on a holistic assessment of my health history, symptoms, goals, and laboratory findings, and are not a diagnosis, cure, treatment, or prescription for any medical condition.

    I understand that any educational content produced by Just In Health including YouTube videos, podcast episodes, blog posts, and social media is for general educational purposes only. That content does not constitute a clinical recommendation, does not establish a doctor-patient or chiropractor-patient relationship, and should not be interpreted as advice specific to my health situation.

    By participating in phone or video visits, I acknowledge and consent to remote wellness consultations. While Just In Health takes reasonable steps to protect my privacy, all electronic communications may carry some privacy, security, or technical risk. I acknowledge that I understand the wellness-focused nature of this practice and consent to receiving services within that scope.

    Results vary significantly based on individual factors including genetics, lifestyle, compliance, severity of imbalance, duration of symptoms, and response to interventions. Just In Health and Dr. Justin Marchegiani make no guarantee, expressed or implied, that any specific outcome, improvement, or resolution of symptoms will result from wellness consultations, protocols, supplement programs, or lab testing. Past results experienced by other patients do not guarantee similar results for me. Testimonials and case examples are individual experiences and are not representative of typical outcomes.

    Communication Outside Consults

    Email is acceptable for brief questions that can be answered in 1–2 sentences. For anything beyond that, the clinic reserves the right to direct you to schedule a consultation. Detailed health questions, changes in symptoms, and treatment-related concerns often require back-and-forth dialogue with Dr. Justin and are best addressed during dedicated consultation time where he can give your question the full attention it deserves.

    Please do not use email for emergencies, urgent symptoms, or time-sensitive matters. Response times are not guaranteed. If the calendar is full, please email and call the office so we can try to assist. If you do not receive a reply within a few days, please follow up by phone and email again.

    Shipping & Handling

    Orders within the mainland U.S. ship via USPS Ground or Priority Mail unless expedited shipping is requested. Additional charges apply for Hawaii, Alaska, and international orders. International shipping fees are billed separately based on weight and distance.

    Just In Health is not responsible or liable for packages that are delayed, damaged, lost, misdelivered, stolen, or marked delivered by USPS or any other shipping carrier once the package has been released to the carrier and sent to the approved shipping address on your invoice. Patients are responsible for confirming that the shipping address is correct before payment and shipment.

    Patients must work directly with the carrier if a package is delayed, damaged, lost, misdelivered, or stolen after shipment or delivery. We are not responsible for customs seizures, VAT/customs fees, carrier delays, delivery errors, theft, weather delays, address errors, or other shipping issues outside of our control.

    Default shipping insurance is $100. If you would like additional insurance, signature confirmation, shipping to an alternative address, or another shipping method, please notify our office before your order ships. These options may involve additional shipping charges.

    If there is an increased risk of stolen, missing, or misdelivered packages at your property, it is the patient's responsibility to request added delivery protections in advance. Any missing items must be reported within 7 days of delivery.

    Lost or Stolen Packages

    If your order does not arrive, email office@justinhealth.com or call 512-535-1817 with your order number, tracking number, and shipping address so we can provide available shipment information to help you file a claim with the carrier.

    Chargeback Policy & Jurisdiction Agreement

    We ask that patients contact our office first with any billing, order, scheduling, or service concern so we can review the issue and work toward a fair resolution. Because consultation time, lab orders, supplements, shipping, and related services cannot be recovered once provided, ordered, processed, submitted, or shipped, patients remain responsible for any products, lab tests, services, appointments, or fees they received, authorized, ordered, incurred, or failed to cancel within the required cancellation window.

    I agree that initiating a chargeback, payment dispute, or payment reversal does not cancel, waive, or eliminate my responsibility to pay any balance owed. A chargeback filed contrary to these signed policies may be disputed and any unpaid balance may be pursued through collections, Texas Justice Court, small claims court, or any other remedies allowed by law, including applicable fees and costs where permitted. I consent to Texas law, jurisdiction, and venue for any dispute or legal proceeding arising from this agreement, unless otherwise required by law. I understand that my electronic signature is legally binding and has the same legal effect as my handwritten signature.

    Patient Disclosure Responsibility

    I agree to provide complete and accurate health information prior to and during all consultations including all current medications (prescription and over-the-counter), nutritional supplements, herbal products, health conditions, recent lab work, surgical history, allergies, and sensitivities. Just In Health and Dr. Justin Marchegiani are not liable for adverse outcomes resulting from incomplete, inaccurate, or withheld information I provide.

    I understand that services provided through Just In Health are not a substitute for medical diagnosis or treatment by a licensed physician. I will continue to see my primary care provider for all medical concerns and will not use these wellness consultations as a replacement for necessary medical care.

    I am aware that some nutritional supplements may interact with prescription medications or affect lab values. I agree to consult my prescribing physician before making any changes to my medication regimen based on functional medicine recommendations. Dr. Justin does not prescribe, adjust, or discontinue pharmaceutical medications.

    Chiropractic Scope Clarification & Texas Chiropractic Board Notice

    All virtual services offered through Just In Health are provided solely in the capacity of a functional medicine and wellness consultant. No chiropractic services of any kind are rendered through any consultation, supplement recommendation, lab order, or written communication associated with this practice. This includes but is not limited to chiropractic examination, spinal assessment, chiropractic diagnosis, manipulation, adjustment, or chiropractic treatment planning.

    Scheduling a virtual consultation does not establish a chiropractic doctor-patient relationship. Virtual services are limited to functional wellness consultation, nutritional counseling, lifestyle guidance, and laboratory interpretation. These services do not constitute the practice of chiropractic as defined by Texas Occupations Code Chapter 201 and are not regulated chiropractic services under the Texas Chiropractic Act. They are not subject to oversight by the Texas Board of Chiropractic Examiners (TBCE).

    I acknowledge that I am receiving functional wellness and nutritional consultation only, not chiropractic care. If I have musculoskeletal complaints, spinal concerns, or conditions requiring physical examination, I understand I should seek care from a licensed chiropractor or appropriate provider in person. I agree that no chiropractic doctor-patient relationship has been established and I will not characterize any recommendation or communication from Just In Health as chiropractic advice or treatment.

    Privacy & HIPAA

    Just In Health is committed to protecting my personal health information in accordance with applicable federal and state privacy laws, including HIPAA where applicable. My information will not be sold, rented, or shared with third parties except as required by law or as necessary to support my wellness consultations.

    I authorize Just In Health to contact me by my preferred contact method for appointment reminders, order updates, and general office communications. I understand that email and text communications are not fully secure and consent to their use.

    Patient Agreement

    By submitting this form I acknowledge that I have read, understand, and agree to all policies and terms above, including financial policies, cancellation policies, communication guidelines, lab and supplement policies, shipping and refund policies, and remote care and telehealth terms.

    I authorize Just In Health to request records, lab results, imaging, or other health information from my prior or current healthcare providers as needed to support my wellness consultations. I understand I may revoke this authorization at any time in writing.

    I understand and acknowledge that the services provided by Just In Health are limited to functional wellness and nutritional consultations only. They do not constitute chiropractic care, do not constitute the practice of chiropractic as defined by Texas Occupations Code Chapter 201, and are not subject to oversight by the Texas Board of Chiropractic Examiners (TBCE) under the Texas Chiropractic Act. No chiropractic doctor-patient relationship has been formed.

    I understand and acknowledge that services provided do not constitute medical diagnosis, treatment, or prescription, and are not subject to oversight by the Texas Medical Board (TMB). Dr. Justin Marchegiani is not a medical doctor and does not hold a medical license. He is not acting as a physician in a medical capacity, does not diagnose or treat disease, and does not prescribe medication through this practice.

    I agree to all terms and conditions and understand they may be updated from time to time. The most current version will always be posted at justinhealth.com/terms-of-service. I understand that my electronic submission is legally valid and equivalent to my handwritten signature.

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