Christian Wellness Group

Appointments
Home | About Us | Appointments | Cold Laser Therapy | Office Visit Fees | Ideal Protein Weight Loss | Counseling | Free Mini-Seminars | Contact Us

~ In-office, Online or Onsite Housecall~
If you would like to make an in-office visit appointment, please call   Back To Wellness at (706)557-0211 or fill out the box below. You will fill out all appropriate paperwork when you arrive at our office. Please plan on arriving a few minutes early. If you are a Cobb County resident, you may request an onsite naturopathic housecall visit. Please fill in the form below and submit for more info.

Type Your Name Here
Type Your Email Here
Type time & day you are requesting here
Type your reason for visit here
  

For an online visit or for a housecall visit (Cobb County Residents only) please fill out the registration form below. You will be required to pre-pay your consult fee. We will be in touch with you to confirm your online appointment request.

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!
candleforjesus.jpg