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.

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
Payment is due at the time of consultation:

Payment is due at the time of consultation.

Accepted payment methods: electronic money transfer, Visa, MasterCard,

Discover, American Express, and debit cards.

Credit card information is securely stored in an encrypted format to ensure payment for services rendered.

Billing Details

Consultations are billed based on the actual time used, not the time block originally scheduled.
Patients often underestimate the time needed to address all concerns. The doctor’s focus is clinical care and will not manage or monitor session time on the patient's behalf.
New patient consultations may run longer depending on the complexity of the case.
After-hours follow-up consults for existing patients incur an additional $100 fee.

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 30-, 45-, or 60-minute time blocks. 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.

6-Month Consultation Policy

If more than 6 months have passed since your last consultation, a new patient consult may be required. This allows sufficient time to reassess your current health status, review any changes or challenges, and update your care protocol accordingly.

The longer the time between visits, the more time and clinical effort is required to properly evaluate your case. A significant gap may necessitate a more comprehensive intake and review process to ensure your plan remains appropriate, safe, and effective.

This policy is ultimately at the discretion of Dr. Justin, based on clinical judgment and the complexity of your case.

All scheduling and consultation policies are subject to change and will be reflected in our most current Terms of Service and New Patient Forms.

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.

You will be contacted to schedule a follow-up appointment if you aren’t already on schedule.

Specific blood work can be billed to the patient’s insurance; this depends upon your insurance type and deductible. Cash discount options can be used to purchase blood work when insurance is unavailable. The patient is responsible for any lab work their insurance does not cover.

Per our policy, lab results will not be released until all outstanding balances are paid in full and a follow-up consultation with Dr. J is completed. Providing labs without context and proper review devalues their usefulness and goes against our clinical standards.

Some patients may have multiple labs for Dr. J to review during the new patient consult. Dr. J can review 1–3 shorter lab tests during this visit. To set aside time to review labs before a new patient consultation or follow-up, there may be a lab interpretation fee of $100–$300, depending on the number of lab pages.

Lab results are emailed to patients the day before their scheduled follow-up consultation.

It is our policy to hold lab results until this time because reviewing lab data without proper clinical context can cause unnecessary anxiety, distress, and even sleepless nights.

We strongly believe in reviewing results directly with Dr. J, as this provides a clear, guided interpretation and ensures you fully understand what your results mean and the next steps.

If patients choose to cancel after receiving their lab results, they may do so; however, we highly encourage everyone to wait and review them together to minimize worry and avoid misunderstandings.
Sign here to confirm fee schedule:*

Powered by Jotform SignClear
Cancellation Policy

If you need to cancel, please reschedule using our online scheduling system. Click here for instructions.

Cancellations require at least 3 business days' notice to avoid fees.

Missed consultations will be billed at the full scheduled consult fee.

Dr. Justin often has a waiting list, and missed appointments take time away from other patients needing care.

As a courtesy, appointment reminders are sent when the appointment is booked and again 1–7 days prior.

Reminder emails are not guaranteed due to spam filters—missing one is not an acceptable reason for a missed consult. Mark our emails as "safe" to improve delivery.

If The Doctor Is Running Late

Please remain available for the full consult window in case Dr. Justin is running late due to prior appointments.

If you are unavailable at the time of your consult, a missed consult fee will be charged in full.

Super-Bills

All receipts provided at checkout contain CPT codes and ICD-10 codes, which you may submit to your insurance for potential reimbursement.

To submit a claim, we recommend calling the customer service number on the back of your insurance card for instructions.

Please note, the doctor and clinic are not responsible for insurance claims that are not reimbursed.

Super-bill adjustments are subject to a $5 administrative fee per receipt.

Any in-depth paperwork requiring Dr. Justin’s completion will be billed to the patient at the doctor’s hourly rate.
Sign here to confirm cancellation, appointment and super-bill policies:*

Powered by Jotform SignClear
Refunds & Returns

All sales of supplements and laboratory tests are final. No refunds or exchanges are available once purchased.

All supplement ingredients are listed on our online store. Patients must review and confirm there are no allergens or sensitivities before placing an order.

The best time to review ingredients and sensitivities is during the supplement program design with Dr. J.

Consultation fees are non-refundable, as time is specifically reserved for your session and cannot be recovered once delivered.

We do not replace or refund packages marked as delivered by the shipping carrier.

We are not responsible for stolen or missing packages after delivery.

For packages lost in transit (not marked as delivered), claims must be filed directly with USPS or the shipping provider’s insurance.

Any fraudulent chargeback claims will be formally disputed and may be referred to a collections agency for resolution.

Important Notes

Dr. Justin is not a medical doctor and does not treat or diagnose medical emergencies.

If you are experiencing a medical emergency, call 911 or contact your primary care physician.

Dr. Justin does not provide chiropractic care.

His role is to support physical and chemical stress imbalances with the goal of promoting wellness—not to diagnose or treat disease.

Patients are seen via phone or video. Due to these limitations, it is essential that all patients have seen a primary care physician within the past year for an in-person exam.

By receiving care, you acknowledge that you have seen or will see a primary care provider for necessary in-person evaluations.

Communication Outside of Scheduled Consultation

Email is acceptable for brief questions that can be answered with “yes” or “no,” or in 1–2 sentences.

Treatment-related questions, changes in symptoms, or complex issues should be addressed during a scheduled consultation.

If no time is available on the calendar, please email and call the office so we can try to accommodate your request.

If you do not receive a reply to your email within a few days, please follow up with a phone call.

Dr. Justin does not prescribe medication. For refills, contact the original prescribing physician.

For any medical emergency, call 911 immediately.

Shipping & Handling

Orders within the mainland U.S. are shipped via USPS Ground or Priority Mail, unless otherwise requested. If you need your order quickly, please request expedited shipping to ensure faster delivery.

Extra charges apply for orders shipped to international countries, as well as Hawaii and Alaska. Please email us if you have any questions.

International orders are shipped by USPS Mail International Priority. Please get in touch with the office for any international shipment requests. If you require expedited shipping, please email us for UPS Expedited Worldwide shipping options. International shipping fees will be charged on a separate invoice once distance and weight costs are calculated.

The clinic is not responsible for shipping issues as long as the products are sent to the address approved by the patient in the invoice.

The patient is responsible for making arrangements with delivery services if the package is damaged, lost, or stolen.

The clinic is not responsible for packages seized by customs or any VAT or customs fees incurred.

The default insurance coverage for all shipments is $100.

If you would like to purchase additional insurance coverage, please contact the office before shipping.

If you would like to request signature confirmation upon delivery, please let us know in advance so we can add this option to your shipment.

These situations rarely occur, but if they do, we can assist in filing a claim with the shipping carrier.

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.

Lost or Stolen Package Guide

What to Do If Your Order Doesn’t Arrive:

Report the Missing Package

Please email us at office@justinhealth.com or reply to your order confirmation.

Include:

Your order number and shipping date
The carrier (e.g., USPS, UPS, FedEx) and tracking number
Your shipping address (apartment or house)
Any delivery notices or photos (e.g., empty doorstep, delivery notice slip)

Signature Confirmation for Future Orders
To help prevent future delivery issues:

Please let us know your preferred delivery setup or any special instructions for a safe drop-off.

If you have any questions, please email us at office@justinhealth.com or call 512-535-1817.
Sign here to confirm communication, important notes, refunds and shipping policy:*

Powered by Jotform SignClear

Clinic Policies and Procedures
Name*

First NameLast Name
Signature confirming clinics policy and procedures:*

Powered by Jotform SignClear
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 SignClear
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