Health Information form
Screening Questionnaire form
Body Map for Clients
Health Status Update form
Client Feedback form
Physician's Permission form
Physician's Referral form
Billing Information form
Our goal is to be a long term part of your health solution. These forms help us maintain a complete health history on you. A complete health history will allow us to map your progress and provide other members of your health care team needed information. Forms may be printed, completed and bought to our office at the time of your visit. Forms can be scanned and emailed to chowell307@aol.com once you have completed them. If forms are sent via email we will load your information to our database prior to your scheduled appointment. All appointments are confirmed within 48 hours of scheduled appointment time. If we are unable to confirm your scheduled appointment it will be canceled (see cancelation policy).
The Health Information form will help us to identify if you have conditions that may contra-indicate certain types of modalities. This will allow us to customize a session to fit your needs. *****Please make certain to advise if you have been diagnosed with PTSD.
The Health Status Update forms can be used to advise of new information since our last session.
The Client Feedback form provides us with information that will help us to improve our service to you. We ask the you are constructive in providing feedback. We may contact you to clarify and discuss any concerns share with us. We may post feedback (positive and negative) website, Google, Facebook, Yelp, WellnessMD or other on line sites for potential clients to review.
The Physician's Permission form, Physician's Referral form, and Billing Information form are needed if you have been referred by your primary care provider and will be using insurance to help pay for services.
* If you are being referred by a primary care provider we will need the original written referral at time of visit. If you are planning on using insurance to help pay for services, you will be responsible for emailing all necessary forms prior to visit or paying a $50 deposit at time of visit. The $50 can be refunded to you or used towards co-pay once we have confirmed the referral and insurance requirements.