Premiere Healthcare
Nutrition Consent Form
Please complete this registration form
start
 
What is your full name? *

As it appears on your ID or driver’s license
 
Do you have any address or other personal information to update *

If you answer no you will but forwarded to the next section.


 
What is your date of birth? *

Format Example: XXXXXXX
 
What is your street address?

 
What is your city and state?

 
What is your postal or zip code?

 
What is your phone number?

Please enter the best available phone number to reach you.
 
Who were you referred by?

 
What is your age?

 
Who is your emergency contact?

 
Place/Type of Employment

Needed to assess any possible environmental/work-related exposure to toxins
 
Relationship Status


 
We will provide a receipt for you to submit to your insurance.  You are responsible for payment in full at the time of service. *

** I clearly understand that all services rendered me are my responsibility and payment is expected at the time of service.
     
 
Nutritional Informed Consent *


According to the Federal Food, Drug, and Cosmetic Act, as amended, Section 201 (g) (1), the term “DRUG” is defined to mean: “Articles intended for use in the Diagnosis, Cure, Mitigation, Treatment or Prevention of disease.” A vitamin is not a drug, NEITHER is a Mineral, Trace Element, Amino Acid, Herb, or Homeopathic Remedy. Although a Vitamin, a Mineral, Trace Element, Amino Acid, Herb or Homeopathic Remedy may have an effect on any disease process or symptoms, this does not mean that it can be misrepresented, or be classified as a drug by anyone. Therefore, please be advised that any suggested nutritional advice or dietary advice is not intended as a primary treatment and/or therapy for any disease or particular bodily symptom. Nutritional counseling, vitamin recommendations, nutritional advice, and the adjunctive schedule of nutrition is provided solely to upgrade the quality of foods in the patient’s diet in order to supply good nutrition supporting the physiological and biomechanical processes of the human body.  Nutritional advice and nutritional intake may also enhance the stabilization of chiropractic adjustments and treatment.
     
 
Cancellation Policy *

We respect the fact that you may, on occasion, may need to reschedule or cancel an appointment.  However, we do request 48-hours notice for all Nutrition appointments. Should you reschedule or cancel a Nutrition appointment without 48-hours notice, we reserve the right to charge for a Late Cancellation/Missed Appointment Fee of Fifty ($50) Dollars.
     
 
Section 2: Health Information

 
Primary Complaints

Please select your most significant concern

 
Primary Complaints (cont'd)

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Primary Complaints (cont'd)

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Primary Complaints (cont'd)

Please select your most significant concern

 
General Health

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General Health (cont'd)

Please select your most significant concern

 
Lifestyle & Environment

Please select your most significant concern

 
Lifestyle & Environment (cont'd)

Please select your most significant concern

 
Sugeries

Please select your most significant concern

 
Gastrointestinal

Please select your most significant concern

 
Gastrointestinal (cont'd)

Please select your most significant concern

 
Respiratory

Please select your most significant concern

 
Mouth and Throat

Please select your most significant concern

 
Endocrine

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Cardiovascular

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Skin

Please select your most significant concern

 
Ears

Please select your most significant concern

 
Eyes

Please select your most significant concern

 
Feet

Please select your most significant concern

 
Neuromuscular

Please select your most significant concern

 
Behavior Patterns

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Urinary

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Men Only

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Women Only

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Women Only (cont'd)

Please select your most significant concern

 
Allergies

Please select your most significant concern

 
List any medications you are currently taking

 
List any supplements you are currently taking

Thank you for submitting your form.
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