Name
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First Name
Last Name
Date of Birth
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MM
DD
YYYY
Email
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Phone
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(###)
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How did you hear about us?
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Please List All Medication Allergies + Reactions
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Height
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Current Weight
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Desired Weight
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Please list major family illnesses
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Please include who in your family was affected by this.
When was the last time you remember feeling really healthy and vibrant?
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Primary Health Concerns
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List up to 3, we will focus on these first
Secondary Health Concerns
Do you have a history of the following?
Please click all that apply
Do you have any current major life stressors? If so, what?
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Are you pregnant, trying to become pregnant, or nursing?
When did you last have lab work done and which lab do you typically use?
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If perfect health is 10/10, how would you rate your current state of overall health?
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What are your long-term health goals?
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What are you willing to do to achieve your health goals?
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Is there anything else you would like to share to help us better appreciate your needs and provide excellent care?
Symptom Survey
Section 1 (H)
Symptom Survey
Section #2 (N)
Symptom Survey
Section #3 (G)
Symptom Survey
Section #4 (A)
Symptom Survey
Section #5 (Th)
Symptom Survey
Section #6 (P)
Symptom Survey
Section #7 (T)
Symptom Survey
Section #8 (O)
Declaration + Consent to Treatment
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Greetings and welcome to Good Medicine. We consider it an honor and a privilege to be a part of your healing journey. Our practice seeks to be the conduit for healing, wholeness, and wellness. While we value and believe that there are illnesses, injuries, and client complaints in which conventional medicine is necessary, we also recognize that many present-day concerns can be drastically reduced or even resolved when care is patient-centered, wellness-promoting and illness-preventive. As such, we serve our client using essential principles of Functional Medicine – thorough health history assessment, comprehensive exam and lab work, diet and lifestyle modification, nutritional supplements, nutritional IV and injections, coaching/counseling, etc. Through these treatment plans, we aim to reverse disease, restore proper function, help you to thrive and experience all you are designed for.
While care is provided through well-practiced hands, the human body is complex and sometimes will exhibit symptoms of underlying problems that have not yet been fully vetted. These symptoms tell us something about the body and it is important that we listen. At times, clients can experience initial worsening of symptoms, hyperreactive and/or vasovagal response, and bruising from injection/IV therapy. Although our treatment approaches are very gentle, there are certain conditions and age groups that may require
adjustments of therapy; these include: pregnancy, nursing mothers, infants/toddlers, fragile and elderly, and those with complex chronic disease (liver, kidney, heart, bleeding disorders, endocrine problems, etc.). For these reasons, it is important that you inform your Good Medicine provider of any health changes, problems, or complications that may occur prior, during, or after your care. Full disclosure affords us the opportunity to provide you with the best care possible. Further, we honor and appreciate the opportunity to partner with your other health care providers; communication between providers is important and we welcome the collaboration.
To ensure that you receive optimum care, we ask that you make a commitment to yourself and your health. Within our practice, this means having regular labs (when appropriate) to track progress and identify opportunities, arrive on time and consistently for your scheduled visits, work to make recommended life changes, and reach out if you need help. We are honored to serve you, but cannot assist in your healing if you are not fully committed to this process.
As a client of Good Medicine, we ask that you understand the following:
• A comprehensive health record will be retained and you are permitted to have access to certain aspects of
these records as required by law. You can request printed copies of these records for the standard fee as described by our office policies. Your records will be kept confidential, in compliance with our HIPAA Notice +
Privacy Practices.
• Optimized health outcomes are not guaranteed as there are numerous factors that dictate your success (i.e.
adherence to treatment plans, your commitment to care and lifestyle modifications, resistant health disorders that are treated by outside providers, etc.). Your consent to various treatments offered is completely voluntary.
• Acceptance of full financial responsibility of fees incurred during diagnosis and treatment provided. Further, charges are to be paid in full at the time of the visit unless other arrangements have been explicitly described prior to your visit.
• Our cancellation policy requires our clients to reschedule and/or cancel a booked appointment 24 hours prior to a visit to ensure that we are allowing for other clients to be seen. 50% of the missed office visit fee will be
incurred and must be paid prior to the next visit.
• We reserve the right to cancel a client relationship should behavior become abusive, disruptive, disrespectfu l,
or should fees incurred not be paid promptly and sufficiently. As such, we respectfully ask that our clients understand that kindness, professionalism, and respect be present in each and every interaction.
Full Legal Name
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First Name
Last Name
Full Legal Name of Guardian
For all clients under 18 years old
First Name
Last Name
Date of Birth
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MM
DD
YYYY
Today's Date
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MM
DD
YYYY
Electronic Signature Agreement
By selecting "I accept", you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual signature on this document.
