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  • Optimum Wellness | Functional Medicine

  • New Patient Intake Form

  • Patient Information

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  • Gender:
  • Format: (000) 000-0000.

  • How did you hear about us?

  • Type a question

  • Previous IV Therapy Experience:

  • Have you ever received IV therapy before?
  • Have you ever received Ozone Therapy before?
  • Preferred Method of Contact:

  • Emergency Contact Information:

  • Format: (000) 000-0000.
  • Reason for Visit (check all that apply):
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  • Medical History (check all that apply):

  • Medical History (check all that apply):
  • Physician-Guided Nutritional Support： To optimize your therapeutic outcomes and support long-term recovery, our physicians provide evidence-based recommendations for high-potency, clinical-grade supplements tailored to your specific health goals and lab results.

  • Lifestyle Overview:

  • Quality:
  • Stress level:
  • Exercise:
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  • Functional Medicine – Informed Consent

  • Functional medicine focuses on personalized, integrative approaches to health. I understand that these services are provided as supportive care to enhance quality of life and are not a substitute for emergency, primary, or specialist medical care (such as neurology).

  • Results may vary and no outcomes are guaranteed. I agree to maintain a relationship with my primary physician or specialist for routine and urgent medical needs.

  • I understand that Optimum Wellness does not bill insurance. I am financially responsible for all services received. All services and treatments provided are non-refundable.

  • I acknowledge and consent to receive functional medicine services.
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  • Ozone Therapy Safety Screening (Required for Ozone Patients):

  • 1. G6PD Deficiency: Have you ever been diagnosed with G6PD deficiency (also known as Favism)?
  • (Note: G6PD testing is required before high-dose ozone therapy)
  • 2. Thyroid Health: Do you have an overactive thyroid (Hyperthyroidism) that is currently untreated or uncontrolled?
  • 3. Blood Concerns: Have you had any recent internal bleeding, or have you been diagnosed with a low platelet count?
  • 4. Pregnancy: Are you currently pregnant or nursing?
  • Ozone Therapy Informed Consent Addendum: I understand that Ozone Therapy involves the use of medical-grade oxygen and ozone. I acknowledge that I have been informed of the potential for a "Herxheimer Reaction" (detox symptoms such as temporary fatigue or headache). I confirm that the information provided above is accurate.
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  • Optimum Wellness: 313 W Old Country Rd. Hicksville, NY 11801 | Tel: 516-376-6063
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