Colon Therapy Registration and Screening Health History Form

Colon Therapy Registration and Screening Health History Form

Complete this form for Expedited Colon Hydrotherapy ONLY. This information will be used for screening and registration purposes. In order to qualify, you must NOT have any major health issues or severe digestive problems. Once your form is submitted, we will review your request and if approved, you will be scheduled for a Medical intake by one of our providers and your first Colon Hydrotherapy treatment. The charge for this visit and treatment is $376. Colon Hydrotherapy is not advised as a single session, the benefits typically only observed after undergoing six to twelve weekly sessions. You are not required to finish this form in one sitting. You have the option to save your progress by scrolling to the bottom and clicking "Save." Then, you will be prompted to create an account which will send you an email with a link to complete this form at your convenience. (If for some reason you do not receive the email with the link, please look in your spam folder.) This form must be completed BEFORE your initial office visit can be scheduled.
Patient's Name*
Phone Number*
Email*
example@example.com
Sex*
Date of Birth*

MonthDayYear
Address*
Without special agreement and arrangements, we are unable to accommodate patients who are not ambulatory due to the extra staff necessary for assistance. If you are in a wheelchair and wish to be a patient, you will need someone to come to all sessions with you as an assistant. Are you able to walk without assistance?*

YesNo
Please indicate which type of office visit you prefer:

Expedited Colon Therapy New Patient Visit and first colonic - Raleigh ($376)Expedited Colon Therapy New Patient Visit and first colonic - Wilmington ($376)
If you purchase a package of 4, 6 or 12 colonics at the time you schedule your New Patient Expedited Colon Therapy visit, the charge for each session will be $96, A 20% DISCOUNT OVER THE STANDARD RATE. I WOULD LIKE TO ADD THE FOLLOWING COLONIC PACKAGE:

4 Colonics - $3846 Colonics - $57612 Colonics - $1152I will pay for each colonic individually at $120 per session after my New Patient visit.I am interested in a package 6 Colonics to purchase at a future time- $684 (5% discount)I am interested in a package of 12 Colonics to purchase at a future time - $1296 (10% discount)
A non-refundable application fee of $100 is payable upon receipt of this form. The balance is owed prior to your initial visit. Once scheduled, patients will be allowed one opportunity to cancel and reschedule at no charge. If this rescheduled appointment is then cancelled again or the patient is a no-show, the patient will need to submit another $100 application fee. No credit will be given for any previous payments made. Please provide credit card information to process this non-deposit.
Name on Card

First NameLast Name
Credit Card Number
Expiration Date

MonthDayYear
Date
Security Code
I authorized the Carolina Center to charge $100 to my credit card

Clear
Please provide a copy or photo of your driver's license (front and back) or other official identification as required by the US Patriot act. Failure to provide these files will delay scheduling.

Cancelof
How did you learn about us?
What condition do you hope to address by undergoing colon hydrotherapy? *
Are you currently under care for this condition?*

YesNo
Explain the care that you are receiving and results*
Do you currently take any medications?*

YesNo
Current Medications*
Do you currently take any vitamins or supplements?*

YesNo
Current Vitamins/Supplements*
Do you have any Allergies/Adverse Reactions or Side Effects to Medications?*

YesNo
List Allergies/Adverse Reactions and Side Effects to Medications*
Hospitalizations, Surgeries and Serious Illnesses*
Recent Medical Care
Current Weight
Height
Digestive System You MUST check at least one option before you submit this form.*

Gallbladder ProblemsIndigestion/HeartburnHemorrhoidsPancreatitisColon polypsRepeated Stomach PainGum ProblemsBelchingChange in AppetiteNausea/VomitingDifficulty SwallowingConstipationBlack StoolsBloody StoolsDiarrhea (longer than 2-3 days)Liver DiseaseAbnormal Liver Function TestsUlcer - type detailsHernias - type detailsColitis - type detailsNone of theseOther
Do you have any of the following digestive disorders:*

Repeated stomach painHeartburnIndigestionGum problemsChange in appetiteNausea or vomitingBelchingDifficulty swallowingVomiting bloodConstipationBlack stoolsBlood in stoolsDiarrhea more than 3 daysHistory of inflammatory bowel diseaseHistory of bowel surgeryRectoceleNone of theseOther
Do you have any of the following:
Any symptoms or history of colon or rectal disorders?*

YesNo
Please explain further*
Any symptoms or history of upper GI disorders (reflux, gastritis, etc.)?*

YesNo
Please explain further*
Any family history of colon polyps or colon cancer?*

YesNo
Please explain further*
Respiratory/Breathing You MUST check at least one option before you submit this form.*

Sinus InfectionHay FeverEmphysemaPneumoniaNose BleedsHead ColdsLoss/Change os smell or tasteHoarsenessSore ThroatSores in Mouth or ThroatChronic CoughCoughing up BloodWaking at Night Short of BreathAllergiesTuberculosisAsthmaNone of theseOther
Heart/Circulation You MUST check at least one option before you submit this form.*

Rheumatic Fever, Rheumatic Heart DiseaseHigh Blood PressureAngina, Heart PainsHeart DiseaseChest PainPain radiating into your arms, neck, jaw or shouldersAble to lie flat on your back in bedVaricose VeinsPalpitations/Fluttering of HeartSwelling of Head, Feet or AnklesLeg Cramps while WalkingLeg Cramps at NightShortness of Breath after WalkingHeart AttackHeart MurmurStrokeAneurysmAbnormal EKGHigh CholesterolPeripheral Vascular Disease (Poor Circulation)None of theseOther
Neurological/Nerves You MUST check at least one option before you submit this form.*

Seizure disorder/EpilepsyRecurrent VertigoBell's PalsyNeuritis/Inflammation of a NervePinched NerveFrequent HeadachesSevere HeadachesDizzinessUnconscious SpellsInsomnia/Difficulty SleepingNervouse "Tics"FaintingConcussionNone of theseOther
Kidney/Bladder You MUST check at least one option before you submit this form.*

GlomerulonephritisUrethritisKidney StonesFrequent Bladder InfectionsKidney infection/pyelonephritisPainful UrinationDifficulty Starting UrinationFrequency/Urgency of UrinationIncontinence (Involuntary loss of urine)Blood in UrineNone of theseOther
Please note any other major health or medical problems of which you are aware*
Do you have any special diet or food needs?*

YesNo
What percentage of your diet is raw & uncooked?*

0-25%26-50%51-75%76-100%
What is your daily intake of fiber?*
Have you changed your diet since the development of your condition?*

YesNo
Describe changes*
Do you feel this change has improved your health?*

YesNo
No Perfume-Scented Toiletries Policy

For everyone's sake, please be aware of our No Perfume-Scented Toiletries policy and refrain from wearing any perfume or scented toiletries while at the clinic. Non-compliance may result in you being asked to leave and being assessed a cancellation fee.I have read all the information on the Carolina Center website under “New Patients” and “How to Become a Patient” and understand these procedures. I have read the “Orientation Handbook” and understand this information. I am requesting to become a patient of the Carolina Center and understand that it is highly recommended that I attend the “Introduction to the Carolina Center” Group Orientation prior to my visit although this is not required. Please sign and date that you acknowledge this policy.
I certify that the above information is true and correct to the best of my knowledge.

It is my responsibility to inform my physician if there are any changes in any of the information contained in this form.
Patient/Guarantor Signature*

Clear
Date*

MonthDayYear
Insurance Information
Please note that while Carolina Center does not accept Blue Cross/Shield, Medicare or Medicaid and can only file certain claims with other insurance carriers, we are able to utilize most major insurance for certain labs and prescriptions. PLEASE PROVIDE A COPY OF YOUR INSURANCE CARD SO WE CAN HELP YOU FILE CLAIMS IF ABLE. Do you have health insurance?*

Yes, I have a primary insuranceYes, I have primary and secondary insurancesNo, I do not have health insurance
Are you the policyholder on this primary insurance?*

YesNo
Front of primary insurance card. *

Cancelof
Back of primary insurance card. *

Cancelof
Subscriber's name*
Birthdate of subscriber*

MonthDayYear
Sex of subscriber*
Relationship to patient*
Are you the policyholder on this secondary insurance?*

YesNo
Front of secondary insurance card. *

Cancelof
Back of secondary insurance card. *

Cancelof
Subscriber's name*
Birthdate of subscriber*

MonthDayYear
Sex of subscriber*
Relationship to patient*
Emergency Contact Information
Name

First NameLast Name
Relationship to Patient
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HIPPA Privacy Authorization Form

Do you wish to authorize Carolina Center for Integrative Medicine to release any and all medical information and test results that pertain to you, to someone else?
Authorized Person

First NameLast Name
Relationship to Patient
Should be Empty:

Colon Therapy Registration and Screening Health History Form

Recent Medical Care

Do you have any of the following:

No Perfume-Scented Toiletries Policy

Insurance Information

Emergency Contact Information

HIPPA Privacy Authorization Form