What to Expect on Your First Few Visits

Visit #1 The initial visit will take 40 minutes to an hour; thorough history and exam is taken and may include a neurological and kinesiology exam using nutrition response testing. We will take this information and determine if your case is a good fit for us. If it is, we will order any necessary lab testing and formulate a program designed on your exam findings.

Visit #2 This is my favorite day; it will ideally be a week or two after your initial visit. This is when you will receive a Report of Findings (ROF), lab results and treatment plan that is specific to you. We will map out the meridian points, organ systems, and spinal levels that need to be addressed and corrected.

If you agree with the treatment plan and choose to accept care, we will start your treatment this day.

Treatments will include one or a combination of the following techniques:

• Nutritional Response Testing (determining which supplements are best for you)
• Acupuncture or Acupressure
• Chiropractic
• Neuro-Emotional Technique (NET)
• Webster Technique/Prenatal Care
• Cold Laser
• Myofascial Release
• Cranial Sacral Therapy
• Flex.ion Distraction

Subsequent Visits may include a combination of the above treatments. Treatments are determined by what your body needs to keep moving forward in the healing process.

HIPAA Privacy Disclosure Consent

Privacy of your personal information is an important part of our office providing you with quality care. We understand the importance of protecting your personal infonnation. We are committed to collecting, using and disclosing your personal information responsibly.

All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information.

Uses and Disclosures

1. Your doctor or a staff member may have to disclose your health information up to and including all of your clinical records to another health care provider if it is necessary to refer you to them for treatment of your health condition.
2. It may be necessary for the doctor and members of the staff to use your health information, examination, and treatment records and your billing records for quality control purposes or for other administrative purposes to efficiently and effectively run our practice.
3. Your doctor and members of the practice staff may need to use your information (ex. name, address, email, phone number, and your clinical records) to contact you to provide appointment reminders, information about treatment alternatives, or other health related information that may be of interest to you. Appointment reminders will be sent by email to the email address you provided to us or by calling the phone number provided and leaving a message on your voicemail if there is no answer.
4. As our patient, you possess the right to refuse to give us the authority to contact you regarding the above-mentioned circumstances.

Your Right to Limit Uses or Disclosures

1. You have the right to request that this office restricts how your personal information is used and/or disclosed.
2. If there are health care providers, hospitals, or other individuals or organizations to whom you do not want us to disclose your health information, please let us know, in writing, what individuals or organizations to whom you do not want us to disclose your health care information.
3. We are not required to agree to your restrictions. However, if we agree with your restrictions, the restrictions would have to be in writing and the restrictions will be binding on this office.

Your Right to Revoke Your Authorization

1. You have the right to revoke your consent at any time as long as we have a written statement. This revocation will not apply to any action already taken by the office before receiving the formal written notice.

I have read and understand the above notice. I understand that entering my name on the signature line constitutes a legal signature confirming that I acknowledge and agree to the terms above.

New Client Evaluation

New Client Evaluation

Metabolic Assessment Form

Part I Are there any other major health concerns?

Part II Please rate each of the following on a scale from 0-3, with 0 as the least/never to 3 as the most/always.

Metabolic Assessment Form Continued

Trauma History

Dental History

Toxicity Questionnaire

The Toxicity Questionnaire is designed to aid the practitioner in assessing a patient's or client's potential need for a Clinical Purification™ program.