Download Page: We Need Your Informed Consent and Medical History

Please Download – Print – Complete – and Fax to 512-532-6699

There are 2 docs on this pg to download: 1) Informed Consent 2) Intake Form (Your Medical History and Contact Info)

CLICK HERE for CONSENT FORM

CLICK HERE for INTAKE FORM 13p

Document #1:

Informed Consent (download this document, print, complete, and fax to 512-532-6699)

CLICK HERE!!!!!!! to download the INFORMED CONSENT document

Please read, initial, and sign in all indicated places – then FAX to 512-532-6699.

Please print, complete, and fax the completed Informed Consent Form to 512-532-6699

Summary of the Informed Consent Document:

1. COMPLEMENTARY and ALTERNATIVE treatments may be recommended.  An example would be supplements and vitamins.

2. You can purchase SUPPLEMENTS at the source of your choice.  If you purchase supplements from us, we are marking the cost up from wholesale and will profit from the sale of the supplements.

3. COMPLEMENTARY and ALTERNATIVE treatments are outside of the CONVENTIONAL practice of medicine.

4.  However, if we recommend COMPLEMENTARY methods to you,  there should be scientific evidence or opinion that the approaches we suggest are reasonable, and there is a potential benefit to you.

5.  You have been given the opportunity to ask questions, and the approaches have been explained to you.

6.  You will need a primary care doctor to perform routine exams and screenings for cancer, heart disease, and other diseases.  We do not function as your primary care doctor,  and will refer you to traditional physicians.

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CLICK HERE for INTAKE FORM 13p

Document #2:

Initial Intake Form:  (your medical history and basic demographic info – 13 pgs)

CLICK HERE!!!!!! to Download the Intake Insurance and Past Medical History Questionnaire

Please download, print, complete, and fax back to 512-532-6699

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Summary of the Intake Form – Past Medical History and Insurance Information:

1. Name, address, insurance, etc.

2. Past Medical History – medications, surgeries, illnesses, , family history, etc.

3. Symptom questionnaire.

4.  Your goals for your health.

5.  You have been given the opportunity to ask questions.

6.  You will need a primary care doctor to perform routine exams and screenings for cancer, heart disease, and other diseases.  We do not function as your primary care doctor,  and will refer you to traditional physicians as needed.