Nutritional forms.

Patient Information

Symptom Survey

Rate each of the following symptoms based upon your typical health profile:

Head

Eyes

Ears

Nose

Mouth / Throat

Skin

Heart

Lungs

Digestive Tract

Joints / Muscles

Weight

Energy / Activity

Mind

Emotions

Other

Authorization & Payment Policy

I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims. I understand that the fee for service will be an arrangement between an insurance carrier and myself. Furthermore, I understand that this office will prepare some reports and forms to assist me in making collections from the insurance company and that any amount authorized to be paid directly to this office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment.