• Image field 210

  • 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

  •  - -
  •  -
  •  -
  •  -
  •  - -

  • Employment Status

  • Spouse Information

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











  • 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.

  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows

  • Just In Health Policies & Procedures

  • Fee Schedule
    New Patient Consultation with Dr. J: $399 (average 45–60 minutes).
    Follow-up consultations for existing patients:
    45–60 minutes: $299
    30–45 minutes: $225
    1–30 minutes: $150
    Payment is due at the time of consultation. Accepted payment methods include electronic money transfer, Visa, MasterCard, Discover, American Express, 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
    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 sent the day before your follow-up consult only upon request. Many patients feel anxious when reviewing results without context, even when everything is normal. Reviewing labs with Dr. J ensures correct interpretation and a personalized plan. Lab values alone can be misinterpreted; the value comes from the plan created during your visit.
    All recommendations are based on the full clinical picture and may change over time as symptoms, history, testing, and response to care evolve.
    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: https://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 your discretion as part of a functional medicine wellness program. To the fullest extent permitted by law, you assume responsibility for monitoring your response. Just In Health Wellness Clinic, Dr. Justin Marchegiani, and clinic staff are not liable for individual supplement reactions or sensitivities.
    Cancellation Policy
    If you need to cancel or reschedule, please use our online scheduling system: https://justinhealth.com/reschedule. To avoid fees, all changes must be made at least 3 business days before your appointment. Business days exclude weekends and federal holidays. Any cancellation or rescheduling request made inside this window is considered a late cancellation and will be billed at the full value of the scheduled consult. A missed consult (no-show) is billed at the same rate. Patients are responsible for keeping track of their appointment date and time, regardless of email reminder delivery. Requests are timestamped at the time they are submitted through the scheduling portal.
    We understand that unexpected conflicts can happen. This policy simply ensures we have enough notice to offer your appointment to another patient who may be waiting for care.
    Online Scheduling
    Our online scheduling system automatically prevents cancellations or changes inside the 3-business-day window. If the system does not allow you to move or cancel your appointment, it means the deadline to reschedule your consultation has passed and a missed consult fee will apply if you cannot attend the scheduled time.
    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 supplement and laboratory test sales are final. No refunds or exchanges. Patients must review all product ingredients on our online store and confirm there are no allergens or sensitivities before ordering. Consultation fees are non-refundable, as the appointment time is reserved for you and cannot be recovered once delivered. We do not replace or refund packages marked delivered by the carrier. We are not responsible for stolen or missing packages after delivery. 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.
    Important Notes
    Dr. Justin is not a medical doctor and does not diagnose or treat medical emergencies. For emergencies, call 911 or contact your primary care physician. Dr. Justin does not provide chiropractic care. His services focus on supporting physical and chemical stress imbalances to promote wellness, not diagnosing or treating disease. All care is provided by phone or video. Because this is a remote practice, patients should maintain an ongoing relationship with a primary care provider for necessary in-person exams and medical evaluations. By receiving care, you acknowledge that you have an established primary care provider or will establish one as needed for in-person medical care.
    By participating in phone or video visits, you acknowledge and consent to remote care. While we take reasonable steps to protect your privacy, all electronic communications and telehealth services may carry some privacy, security, or technical risk.
    Communication Outside Consults
    Email is acceptable for brief questions that can be answered in 1–2 sentences. Any treatment-related questions, changes in symptoms, or detailed concerns require a scheduled consultation. 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.
    Dr. Justin does not prescribe medication. For prescription refills, contact your prescribing physician. For emergencies, call 911.
    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. The clinic is not responsible for shipping issues once a package is sent to the approved address on your invoice. Patients must work directly with the carrier if a package is damaged, lost, or stolen after delivery. We are not responsible for customs seizures or VAT/customs fees. Default shipping insurance is $100. If you need additional insurance or signature confirmation, notify the office before shipping. Products manufactured by Dr. Justin include a 30-day limited warranty against defects. 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, shipping date, carrier, tracking number, shipping address, and any delivery notices or photos. For future orders, you may request signature confirmation and additional insurance for secure delivery.
    Patient Acknowledgment and Agreement
    By signing below, I acknowledge that I have read, understand, and agree to the policies and terms above, including financial policies, cancellation policies, communication guidelines, lab and supplement policies, shipping and refund policies, and remote care/telehealth terms.

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

  • Payment Authorization Form

  •  - -
  •  
  • Should be Empty: