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  • New Patient Packet

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  • Format: (000) 000-0000.

  • Superior Health Solutions Financial Office Policies

    1) All patients are on a cash basis.

    2)This office accepts MC, VI, DC, AX, Cash and Checks.

    3) If this office give you any professional or accounting discount for treatment an you decide to drop out of care then our standard fees will apply when a refund is issued.

    4) If you have any questions concerning this or any other matter, please speak with the receptionist prior to seeing the doctor.

    5) If you stop care and have a financial agreement signed with our office, you will be responsible for any/all charges that you have incurred at our office.

     

    Thank you for your cooperation in this matter.

    I have read and fully understand the financial office policy and agree to abide by these terms.

  • Have you received a diagnosis for ANY condition by another health care provider?*

  • Please check each that may apply.

  • Metabolic Symptoms
  • Thyroid Symptoms
  • Neurological Symptoms
  • Physical/Structural
  • Other

  • Medication and Dosage . Reason for medication .

  • Medication and Dosage . Reason for medication .

  • Medication and Dosage . Reason for medication .

  • Medication and Dosage . Reason for medication .

  • How many times per week do you get the recommended 15-20 minutes dosage of ultra violet rays (sunlight from the sunrise to 10am)?
  • How much time do you spend on your cell phone per day? (including looking at emails, social media, playing games, making phone calls)
  • How much time do you spend on your computer per day?
  • Do you wear blue blocker glasses?
  • Do you have EMF blockers?
  • How much sunlight do you get a day
  • What type of water do you drink?
  • How much sleep do you get a night?
  • Do you sleep through the night?
  • Do you exercise?
  • Does your work activity mostly involve?
  • Do you work Day/Swing/Graveyard Shift?

  • Caffeine cups/day.
    Alcohol drinks/week.
    Cigarettes packs/day.

  • Have you ever been exposed to mold?
  • Have you ever been exposed to chemicals (work,pesticides, etc.)?

  • Dental History

  • Do you have (had) any non-tooth colored fillings (ie. silver or gold)? . How many? .

  • Have you had any fillings removed? . How many? .

  • Have you had any root canals? . How many? .

  • Other dental fixtures? . If yes describe. .

  • Have you ever taken Fosamax? . If yes, how long ago? .

  • Is there anything else you would like Dr. DeMartino to know ?

  • Consent to Care

     

    A patient coming to the doctor gives him/ her permission and authority to care for them in accordance with appropriate test, diagnosis, and analysis. The clinical procedures performed are usually beneficial and seldom cause any problem. In rare cases underlying physical defects, deformities or pathologies, may render the patient susceptible for injury. The doctor, of course, will not provide specific healthcare, if he/ she is aware that such care may be contraindicated. It is the responsibility of the patient to make it known or to learn through health care procedures from whatever he/ she is suffering from: latent pathological defects, illnesses, or deformities, which would otherwise not come to the attention of the physician.

    I agree to settle any claim or dispute I may have against or with any of these persons or entities, whether related to the prescribed care or otherwise, will be resolved by binding arbitration under the current malpractice terms which can be obtained by written request.

    I have read and understand the foregoing.

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