Christian Wellness Group
Forms
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For in-office visit, please click here to print the Registration Form and bring it in at your appointment.

*Note: There are other forms you may be asked to fill out while in our office depending on your type of visit with us*

For ONLINE visits only, please fill out the registration form below.

Full Name:
Age
Address
Date
E-Mail Address:
Current Problem(s) and how long you've had?
Have you ever visited a natural health facility?
If yes, describe your experience.
Do you have a current medical doctor or chiropractor?
If so, give their information please.
List any medications or supplements you are taking.
List any former ailments, surgeries, hospitalizations, etc.
List any family medical history.
Do you frequently use any of the following?Aspirin
Laxatives
Antacids
Diet Pills
Birth Control
Alcohol
Tobacco
Caffeine
Recreational Drugs
How many times have you used Anti-biotic drugs?
Please indicate what immunizations you've had, if any.DPT (diptheria, pertussis, tetanus)
Flu
Hepatitis A
Hepatitis B
MMR (measles, mumps, rubells)
Small Pox
Polio
Is there anything else you like for us to know in regards to caring for you?
Please read the disclaimer below and type in your name to the right.-->
  

DISCLAIMER FORM                                                                                                                              

Please read.

 

I agree that I am being counseled by natural care practitioner(s) and willingly submit my information to be used at their discretion for the benefit of my health, mentally, physically and spiritually. I understand that I will be given ample time and courtesy to state my health concerns with regards to the utmost respect and privacy optimally to benefit my health from a non-invasive, natural perspective. I will not be prescribed any chemically induced, man-made or narcotic drugs and will not be medically treated as such.

I understand that I will be assessed by a qualified practitioner who will help me make healthcare related decisions for my needs in an all-natural perspective.

I agree that I have the benefit of asking as many questions and voice any concerns as needed. I am aware that my healthcare information and/or records will not be shared with any other party without my explicit approval, thereby complying with confidentiality & privacy requirements.

I am aware that payments are required when services are rendered.

 

 

Disclaimer: We do not advocate the use of pharmaceutical drugs or chemically induced medications. We do not operate as a traditional medical practice by way of offering medical advice and the use of such drugs.
We do, however, operate as a non-traditional, alternative healthcare practice advocating the use of all natural methods & therapies including proper education/counsel & all natural supplementation to the people we care for in our office. If you have any questions concerning the above statement, please email us directly. To your health!
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