New Patient Intake

Health Information
What are your most concerning health issues? (List top 5 max)*
List any medical conditions that run in your family. (Parents, Grandparents, Siblings)*
List any previous surgeries, serious illness or hospitalizations with approximate date.*
List any drug, food or environmental allergies.*
List any medications or nutritional supplements you are currently taking. (Include dosage)*
Are you a cigarette smoker?*

NeverPastYes
Are you a current vegetarian or vegan?*

YesNo
Do you have any food avoidances or special diet that you follow?
Below please list what you eat and drink on an average day.
Breakfast
Lunch
Dinner
Snacks
How many ounces of water per day?
How many cups of coffee per day?
How many alcoholic beverages per WEEK?
List exercise and frequency
Recreational drug use

Clinic Policies
Payment Agreement: Payment for all services, lab tests, and medicinary items are due at the time of service. Stellar Health and Wellness DOES NOT bill insurance. If you choose to have blood work billed to insurance, all billing questions should be directed to LabCorp or the lab you chose to use. Labs not covered by your insurance are your responsibility. You are agreeing to pay any amount due at each visit. We accept all credit cards. Returned checks will be subject to a $35.00 NSF fee.*

I agree
Product Returns: We use a variety of nutritional supplements, homeopathic remedies, and botanical medicines. Once these products leave our office, we cannot bear responsibility for their storage or their use. For the health and safety of our patients, we cannot accept returns on ANY medicinary products.*

I agree
Cancellations and Missed Appointments: If you are unable to make your scheduled appointment, please call the clinic at least 48-hours in advance of your scheduled time. You will be charged a $50 missed appointment fee if you miss a scheduled appointment or fail to cancel at least 48-hours in advance. Text reminders are always sent at least 48 hours prior to appointment.*

I agree
Email Correspondence: Stellar Health and Wellness staff may use email to correspond with patients as a convenience. However, these emails are not encrypted and could theoretically be read by a malicious outside party with the technical skills to intercept such correspondences. By agreeing, you are consenting to allow correspondence by email and to other practitioners necessary for your care in spite of these potential risks.*

I agree

Informed Consent
Signature*

Clear

Consent to Treatment

The therapeutic procedures of naturopathic medicine and acupuncture are considered safe and effective methods of care. Any procedure intended to help may also have complications. While the chances of experiencing complications are small, it is the practice of this clinic to inform our patients about them.

Please read and sign below that you understand the following procedures:

Nutritional supplements, herbs, and homeopathy may be used to aid in healing. Be sure to inform your practitioner about all medications you are taking to minimize drug/supplement interactions. If you believe you are experiencing any side effects from your supplements/herbs/homeopathy be sure to alert your health care provider.

Muscle Testing is a safe and non-invasive natural method of analyzing the body’s physical and nutritional needs. It is not a method of “diagnosing” or “treating” any particular disease.

Dried Blood Cell Analysis is a tool used to help the doctor and patient conceptualize the effectiveness of natural treatments. It does not “diagnose” any particular disease.

Acupuncture is a practice that involves the insertion of stainless steel needles into the skin at specific locations throughout the body. Tingling, bruising, and numbness are possible near the needling sites, as well as dizziness. Rare risks report nerve damage, infection, and organ puncture.

Body Work includes the use of Sotai Therapy, Craniosacral Therapy, and Manual Manipulation. Generally, these are safe methods of treatment, but adverse effects may occur such as muscle soreness, bruising, blood clots, and fatigue.

I have read and understand the above statements. I understand that the health improvement program recommended to me is not for the treatment, or “cure” of any particular disease. No promise or guarantee has been made regarding the results of Muscle Testing, or any natural health, nutritional or dietary programs. Rather, the above will be used for bringing about a more optimum state of health.
HIPAA
YOUR HEALTH INFORMATION PRIVACY RIGHTS

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain privacy rights concerning your health care information. Under this law your health care provider generally cannot give your information to your employer, use or share your information for marketing or advertising purposes, or share private notes about your mental health counseling sessions without your written consent. As one of your health care providers it is our responsibility to keep your information safe and secure. We also need to make sure that your information is protected in a way that does not interfere with your health care. It is important that you understand that your information can be used and shared in the following ways:

For your treatment and care coordination: Multiple health care providers may be involved in your treatment directly and indirectly.

With your family, friends, relatives, or others that you identify who are involved in your health care or health care bills.

To protect the public’s health, such as reporting when the flu is in your area.

To make required reports to the police, such as gunshot wounds.

Obtain payment from third party payers.

In order to provide you with service that best meets your privacy needs, please tell us how best to contact you when needed.
Please check only those that apply or leave blank:

Please do no call my cell phone. Use alternate number listed below.Please do not leave voice messages on my phone.Please do not contact me by email.
Alternate number:
Signature*

Clear
Should be Empty:

New Patient Intake

Health Information

Clinic Policies

Informed Consent

HIPAA