New Patient Paperwork

NEW PATIENT FORM
Dr. Justin Marchegiani D.C.
Phone: (512) 535-1817

Dear Patient,

Welcome! And thank you for choosing Dr. Justin as one of your healthcare providers.

HOW THE PROCESS WORKS:

Please click the "Save" button below before you start in case you can not complete the form in one sitting. Please take no more than 30 minutes to complete this form; all other details can be addressed at the new patient consult.

STEP 1:
During your initial consultation, Dr. Justin will review your health history and make recommendations for lab tests that are appropriate for your specific health issues.

STEP 2:

Once you have completed your lab tests, Dr. Justin will explain the meaning of your test results to you in a follow-up consultation. He will create an individualized therapeutic program for you, including diet changes, nutritional supplements, and exercise, lifestyle, and stress management advice.

STEP 3:

Subsequent consults are scheduled to monitor your progress. Dr. Justin will also design an ongoing wellness program to be reviewed and updated with our staff at no charge every six months. We invite you to contact us via email or phone should you have any questions during the course of your treatment.

We look forward to assisting you in achieving your current wellness goals, and to guiding you in maintaining wellness throughout your life.

You will automatically be enrolled in the clinic's weekly newsletter to provide you with free cutting-edge health information to support you on your health journey. If you wish not to receive the newsletter, feel free and unsubscribe.

Send Over Your Labs:

Please email your labs to office@justinhealth.com. Subject Line: Labs for "Patient's Full Name."

Please name the lab test files you are emailing over like this: (Date of the test, your name, type of test). Example (5-5-17 John Smith blood test or stool test).

This helps to sort through tests and review them faster at your consult.

In Health,

Dr. Justin and the Wellness Team!

Are there foods that you eat on a daily basis, almost daily basis?
Are there any disease that run in your family especially autoimmune disease like Parkinson, Celiac, Hashimotos etc.
Are you happy in your life right now?
What are your main sources of stress?
How do you deal with your stress?
Do you have a history of an eating disorder: Anorexia, bulimia or very low calorie dieting?

YesNo
How often do you exercise and what kind of exercise do you do?
If you do not currently exercise, what types of exercise have you enjoyed doing in the past?
Do you have any history of infections or tick bites?
Please list surgeries and or hospitalizations starting with most recent:Please list surgeries and or hospitalizations starting with most recent:
Briefly describe where you have lived since childhood:
What is your heritage? (Irish, German, Spanish, etc.)

	Yes	No
Extended menstrual cycle, greater than 32 days

Just In Health Policies & Procedures
Fee Schedule:

New patient consultation with Dr. J $399, 45-60 minutes on average.

New patient initial consultation (with new patient coordinator): $325 45-60 minutes on average.

Follow-up consultations for existing patients only:
- 45-60 minute follow-up: $299
- 30-45 minutes follow-up: $225
- 15-30 minutes follow-up $150
- 1-15 minutes follow-up $80
- 30-45 minute nutrition follow consult (Not with Dr. J) $175
Payment is due at the time of consultation:
- Methods of payment are: Check or money order (in advance) Visa, MasterCard, Discover or Debit.
- Follow-up consultations will be billed for the actual time block used, not the time block you schedule. Many patients underestimate how much time is needed to address their concerns.
- New patient consults may go longer depending on how in-depth or complex someone's medical history is.
- After-hour follow-up consults for existing patients are $75 extra.
Late Fees:

A late fee of $5 per day will be applied to bills unpaid after 48 hours unless other accommodations have been made with the office. Click here for more info on our late fee policy.

Appointments

Follow-up consults may be scheduled in 15, 30, 45, or 60-minute blocks of time. We encourage you to book your appointments 4 weeks in advance. As a courtesy to you, our office will email you 3-7 days in advance to remind you of your appointment.

Lab Tests

The results of your lab test(s) will be sent to Dr. Justin 2 to 4 weeks after mailing your specimens to the lab Dr. Justin will evaluate the results. After evaluation, you will be contacted to schedule a follow-up appointment. Certain blood work can be billed to the patient’s insurance, this is dependent upon the type of insurance you have as well as your deductible. When insurance is unavailable, cash discount options can be used to purchase blood work. The patient is responsible for any lab work their insurance does not cover.
Sign here to confirm fee schedule:*

Powered by Jotform Sign Clear
Cancellation Policy

If you are unable to keep your scheduled appointment, please reschedule online using the clinic's email software, for additional instructions click here. The office requires a minimum of 72 hours before your scheduled consult or you will be charged for the appointment time scheduled. Any fraudulent chargeback claims will be disputed and sent to collections.

Dr. Justin has patients waiting over a month to be seen and a missed appointment takes time away from other patients. We require at least 3 days so we can use that time to help someone else get the care they need.

As a courtesy, our scheduling service will email you an appointment reminder the day the appointment is made and 1-7 days in advance before your consult. We can not guarantee patients will receive these reminders because of email and spam filters. Not receiving a reminder email is not an acceptable excuse for a missed consultation. You can also mark these emails as friendly to increase the chance that you will receive them.

If The Doctor Is Running Late

If the Doctor is running late you must be available for the entire time of the consult. The Doctor may be running late with his previous patient, you will be charged a missed consult fee equal to the value of the consult if you are not available.

Super-Bills

All receipts given at check out contain cpt codes and IC10 codes that that can be submitted to your insurance company for reimbursement. The easiest way to do this is by calling the customer service number on the back of the insurance card to receive instructions regarding the submission of your claim.

The Doctor is not responsible for any insurance claims that are not reimbursed. If there are any changes to a super-bill that need to be made, it is the responsibility of the patient to find out from their insurance what needs to be amended. The office will make adjustments to the super-bill at $5 fee per receipt. Any in-depth paperwork that requires that Doctor to fill out will be charged to the patient at the doctors hourly rate.
Sign here to confirm cancellation, appointment and super-bill policies:*

Powered by Jotform Sign Clear
Refunds & Returns
- Pre-approval is required on all returns. Once approved we will provide instructions for the return process.
- Refunds are granted via PayPal to avoid chargeback fees or the refund can be returned to your credit card for a 3% chargeback fee.
- Refunds are given once products are returned and then inspected. Opened supplements, refrigerated supplements or special orders cannot be refunded.
- Supplements (non-special order, unopened and non-refrigerated items) may be returned with a 15% restocking fee of the purchase price for store credit once the products are returned.
- All supplement returns must be requested within 30 days of the invoice date and returned no later than 7 days after the 30-day return window, for a 15% restocking fee.
- Prepaid tests and lab read fees can be returned for credit within 30 days of the invoice date and returned no later than 7 days after the 30-day return window, for a 15% restocking fee.
- All ingredients for Dr. J's supplements can be found in the store as well. It's the patient's responsibility to make sure there are no specific allergens in the supplements before they are shipped, the best time to address this is during the supplement program design. If products are sent and allergies are found after the fact, the above return policy applies.
- There are no refunds for any serviced consultations.
- Any fraudulent chargeback claims will be disputed and sent to collections.
Important Notes
- Dr. Justin is not a medical doctor; he does not service medical emergencies. If you have a medical emergency, you must contact your primary care physician or dial 911!
- Please contact the office if you are not clear on any of our policies or procedures.
- Dr. Justin is not providing you Chiropractic treatment.
- Dr. Justin does not treat or diagnose any medical disease. Dr. Justin’s work is to help support physical and chemical stress imbalances, with the goal of promoting wellness.
- Patients are seen via phone or video mediums need to realize there are physical limitations of not seeing the doctor in person. Due to these physical limitations, it's important that a patient has seen their primary care physician in the last year for an in-person visit to rule out any disease pathologies as well assess any health issues that may be limited via a virtual assessment. By signing below, I agree that I have and or will see a primary care physician if I haven't yet, for an in-person consultation and examination.
Communication Outside of Scheduled Consultation
- Many people now use email as a primary way to communicate with others. We appreciate that email can be a great way to ask a quick question or clarify something from your last visit or share with us how you are doing. Yes or no questions are best with email correspondence. A question that doesn't involve a back on forth dialogue that can be answered in 1-2 sentences is also acceptable.
- We have found through experience, however, that email is often not the best way to deal with more treatment-oriented questions and decisions such as questions regarding your medical issues, changes in your symptoms, or complex requests. Instead, in these cases please schedule an appointment so your doctor will have time set aside to directly hear and address your concerns. If there is no time available on the calendar for a troubleshoot consult, please email and call the office so we can find a time to squeeze you in.
- If you have sent us an email and have not heard back from us after several days, please follow up with a phone call.
- Dr. Justin is not a medical doctor, for any medical emergencies please call 911. If you are in need of refills on prescription medication, please see the original prescribing physician.
Shipping & Handling:
- Within the mainland, U.S. orders are shipped via USPS Ground or Priority Mail, unless otherwise requested. If you require your order quickly, please ask for request expedited shipping to ensure your products arrive sooner.
- Extra charges apply for orders shipped to Internation countries as well as Hawaii and Alaska. Please e-mail if you have questions.
- International orders are shipped by USPS Mail International Priority. Please contact the office for any international shipment requests. If you require expedited shipping, please e-mail for UPS Expedited Worldwide shipping charges. International shipping fees will be charged on a separate invoice once distance and weight costs can be calculated.
- The clinic is not responsible for issues with shipping as long as the products are sent to the address approved by the patient in the previous invoice. The patient is responsible to make arrangements with the delivery services if there is an issue with the package, this includes lost or stolen packages as well.
- The clinic is not responsible for any packages seized by customs.
  Products manufactured by Dr. Justin carry a 30-day limited warranty against defects. Any products missing from your order must be reported within the first week of receiving the order.
Sign here to confirm communication, important notes, refunds and shipping policy:*

Powered by Jotform Sign Clear

Clinic Policies and Procedures
Name*

First NameLast Name
Signature confirming clinics policy and procedures:*

Powered by Jotform Sign Clear
Date*

MonthDayYear
Date

Payment Authorization Form
Name*

First NameLast Name
Billing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Signature confirming payment authorization:*

Powered by Jotform Sign Clear
Date*

MonthDayYear
Date
Should be Empty:

	0	1	2	3
Feeling that bowels do not empty completely
Lower abdominal pain relieved by passing stool or gas
Alternating constipation and diarrhea
Diarrhea
Constipation
Hard, dry, or small stool
Coated tongue or “fuzzy” debris on tongue
Pass large amount of foul-smelling gas
More than 3 bowel movements daily
Use laxatives frequently

	0	1	2	3
Increasing frequency of food reactions
Unpredictable food reactions
Aches, pains, and swelling throughout the body
Unpredictable abdominal swelling
Frequent bloating and distention after eating
Abdominal intolerance to sugars and starches

	0	1	2	3
Intolerance to smells
Intolerance to jewelry
Intolerance to shampoo, lotion, detergents, etc
Constant skin outbreaks

	0	1	2	3
Excessive belching, burping or bloating
Gas immediately following a meal
Offensive breath
Difficult bowel movements
Sense of fullness during and after meals
Difficulty digesting fruits and vegetables undigested food found in stools

	0	1	2	3
Stomach pain, burning, or aching 1-4 hours after eating
Use of antacids
Feel hungry an hour or two after eating
Heartburn when lying down or bending forward
Temporary relief by using antacids, food, milk, or carbonated beverages
Digestive problems subside with rest and relaxation
Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine

	0	1	2	3
Roughage and fiber cause constipation
Indigestion and fullness last 2-4 hours after eating
Pain, tenderness, soreness on left side under rib cage
Excessive passage of gas
Nausea and/or vomiting
Stool undigested, foul smelling, mucous like, greasy, or poorly formed
Frequent urination
Increased thirst and appetite

	0	1	2	3
Greasy or high-fat foods cause distress
Lower bowel gas and/or bloating several hours after eating
Bitter metallic taste in mouth, especially in the morning
Burpy, fishy taste after consuming fish oils
Difficulty losing weight
Unexplained itchy skin
Yellowish cast to eyes
Stool color alternates from clay colored to normal brown
Reddened skin, especially palms
Dry or flaky skin and/or hair
History of gallbladder attacks or stones
Have you had your gallbladder removed?

	0	1	2	3
Acne and unhealthy skin
Excessive hair loss
Overall sense of bloating
Bodily swelling for no reason
Hormone imbalances
Weight gain
Poor bowel function
Excessively foul-smelling sweat

	0	1	2	3
Crave sweets during the day
Irritable if meals are missed
Depend on coffee to keep going/get started
Get light-headed if meals are missed
Eating relieves fatigue
Feel shaky, jittery, or have tremors
Agitated, easily upset, nervous
Poor memory/forgetful
Blurred vision

	0	1	2	3
Fatigue after meals
Crave sweets during the day
Eating sweets does not relieve cravings for sugar
Must have sweets after meals
Waist girth is equal or larger than hip girth
Frequent urination
Increased thirst and appetite
Difficulty losing weight

	0	1	2	3
Cannot stay asleep
Crave salt
Slow starter in the morning
Afternoon fatigue
Dizziness when standing up quickly
Afternoon headaches
Headaches with exertion or stress
Weak nails

	0	1	2	3
Cannot fall asleep
Perspire easily
Under a high amount of stress
Weight gain when under stress
Wake up tired even after 6 or more hours of sleep
Excessive perspiration or perspiration with little of no activity

	0	1	2	3
Edema and swelling in ankles and wrists
Muscle cramping
Poor muscle endurance
Frequent urination
Frequent thirst
Crave salt
Abnormal sweating from minimal activity
Alteration in bowel regularity
Inability to hold breath for long periods
Shallow, rapid breathing

	0	1	2	3
Tired/sluggish
Feel cold―hands, feet, all over
Require excessive amounts of sleep to function properly
Increase in weight even with low-calorie diet
Gain weight easily
Difficult, infrequent bowel movements
Depression/lack of motivation
Morning headaches that wear off as the day progresses
Outer third of eyebrow thins
Thinning of hair on scalp, face, or genitals, or excessive hair loss
Dryness of skin and/or scalp
Mental sluggishness

	0	1	2	3
Heart palpitations
Inward trembling
Increased pulse even at rest
Nervous and emotional
Insomnia
Night sweats
Difficulty gaining weight

	0	1	2	3
Urination difficulty or dribbling
Frequent urination
Pain inside of legs or heels
Feeling of incomplete bowel emptying
Leg twitching at night

	0	1	2	3
Decreased libido
Decreased number of spontaneous morning erections
Decreased fullness of erections
Difficulty maintaining morning erections
Spells of mental fatigue
Inability to concentrate
Episodes of depression
Muscle soreness
Decreased physical stamina
Unexplained weight gain
Increase in fat distribution around chest and hips
Sweating attacks
More emotional than in the past

	Yes	No
Perimenopausal
Alternating menstrual cycle lengths
Extended menstrual cycle (greater than 32 days)
Shortened menstrual cycle (less than 24 days)

	0	1	2	3
Pain and cramping during periods
Scanty blood flow
Heavy blood flow
Breast pain and swelling during menses
Pelvic pain during menses
Irritable and depressed during menses
Acne
Facial hair growth
Hair loss/thinning

	0	1	2	3
Since menopause, do you ever have uterine bleeding?
Hot flashes
Mental fogginess
Disinterest in sex
Mood swings
Depression
Painful intercourse
Shrinking breasts
Facial Hair growth
Acne
Increased vaginal pain, dryness or itching

NEW PATIENT FORM

NEW PATIENT FORM

Just In Health Policies & Procedures

Clinic Policies and Procedures

Payment Authorization Form