New Patient/ Assigned Female at Birth

Legal Name *

First NameLast Name

What name do you like to be called. *

What is your pronoun(s) She/He/They *

Gender*

Date of Birth*

Date

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number*

Please enter a valid phone number.

Other Phone Number

Please enter a valid phone number.

If you are coming in for alternative medicine/weight loss/functional medicine, you are 100% responsible for the cost as it will not be billed to insurance. *

Preferred Pharmacy Name and Location (Walgreens N or S Sebring, Walmart Avon Park etc)*

Emergency Contact Name *

Emergency Contact Phone Number*

Please enter a valid phone number.

I Understand that because of HIPAA laws my information cannot be given unless I authorize it writing. Information regarding my diagnosis and treatment may be given to the following person/people. If you do not wish for your information to be releases to anyone indicate none.*

Insurance Carrier Name (Blue Cross/ Aetna or type NONE)*

Policy/Member Number (Put all Numbers that is on your card Policy/Group)*

If you have insurance, you give consent for Customized Wellness, LLC to bill your insurance and provide any information needed in order to have a claim paid. If you have insurance but do not wish to use is that is your right. Be aware, if you are coming in for alternative/functional medicine insurance will not be billed.*

Bill My InsuranceDO NOT Bill my InsuranceI do not have insuranceI am here for alternative/functional medicine. My insurance will not be used.

What brings you to the office? Annual Exam/Problem/ hormones etc. (Annual exams are not combined with problem visits or hormone visits.)*

If you are here for a problem tell me EVERYTHING! Such as the symptoms you are having, treatment in the past, using anything over the counter etc... or type n/a. *Not being detailed may delay your appointment scheduling. *

Have you seen another provider for this problem. *

List ALL surgeries even if they do not pertain to this visit or type none. *

Are you on a blood thinner?*

Metabolic*

Do you have a cancer history? Where was the cancer? What year? *

Liver Disease/transplant?*

Cardiac history or high blood pressure *

Kidney Disease/transplant?*

Neurological problems/migraine headaches*

History of autoimmune disorder? If so which one(s)? or n/a*

Any Other Medical Problems? Genetic Problems etc... or type n/a*

If you are not menopausal, when was the first day of you last menses? or n/a*

I take Hormones or birth control.*

Marital Status*

Work*

Smoking/tobacco history, including vaping*

Street Drugs*

Alcohol Use *

Exercise regularly *

Typical Diet*

If here for weight loss... tell me what you have tried already or n/a*

Height*

Weight*

Do you have any allergies? If so please list or state none.*

List All medications/doses/reason for taking:*

List ALL supplements/dose or none. *

Is there anything else you need to talk with me about?*

Total Numbers of pregnancies (Include abortions/miscarriage/stillborn/ectopic) or mark n/a and skip the remaining questions.*

Total number of full term births?

Total number of preterm births?

Total number of ectopic pregnancies?

Total number of miscarriages?

Total number of Stillborn?

Total number of abortions?

Total number of children born alive?

I, blanks* give consent for treatment by customized Wellness, LLC. I also give consent for Customized Wellness, LLC to provide documentation to my insurance company in an effort obtain payment. I understand that I have the right NOT to bill my insurance company and pay cash for any services rendered at Customized Wellness, LLC.

Signature of patient/even if a minor*

Signature of parent

New Patient/ Assigned Female at Birth

Medical History

Social History

Pregnancy History