LIGHT NEW PATIENT DISCOVERY FORM

Name

First NameLast Name

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address

example@example.com

Phone#

Format: (000) 000-0000.

Why do you want to use our red light therapy? Choose all that apply:

What have you tried in the past? (supplements exercise cool sculpting liposuction food modifications etc...)

Are you currently doing anything to lose weight/inches?

Any history of eating disorders?

If you are doing this for weigh/inches lost how much weight would you like to lose over the next 60-90 days?

How were did you hear about our office?

Write a brief description of your goals

Any Surgeries? if YES provide details

CHOOSE ANY CONDITIONS YOU WOULD LIKE OUR HELP WITH

Informed Consent to Initiate Care

I have been advised that wellness treatments and therapies, like all forms of health care, hold certain risks. Treatment objectives as well as the risks associated with chiropractic adjustments and therapies, medical grade light therapy, electronic nerve stimulation and nutritional therapy and, all other procedures, provided at Abundant Health Physical Medicine have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care.

Notice of Privacy Practices Acknowledgement Iunderstand that I have certain rights of privacy regarding my protected health information, under

the Health Insurance Portability & Accountability Act of 1996. (HIPAA I understand that this information can and will be used to:

1. Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.

2. Obtain payment from third-party payers.

3. Conduct normal healthcare operations, such as quality assessments and physicians training.

I understand that, in order to ensure accuracy of documentation, support continuity of care, and for internal staff training purposes, my consultations may be audio recorded.

I understand that any such recordings are considered part of my protected health information (PHI) under the Health Insurance Portability & Accountability Act of 1996 (HIPAA).
I consent to the audio recording of my consultations, provided that the recordings are made only on secure, company-issued devices and stored in compliance with HIPAA privacy and security requirements.
I understand that recordings will be used solely for medical record accuracy, patient care, and internal training purposes, and will not be disclosed to unauthorized individuals.
I acknowledge that I may revoke this consent at any time by providing written notice, which will not affect recordings made prior to revocation.

I acknowledge that I may request your NOTICE OF PRIVACY PRACTICES containing a more complete description of the uses and disclosures of my health information. I also understand that I may request, in writing, that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operation. / also understand that you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions.

Print your name

Sign your name

Todays date

Date

ALL NATURAL WEIGHT LOSS NEW PATIENT DISCOVERY FORM