Brief Medical Screening

All services require medical screening and provider approval prior to treatment. Submitting this form does not constitute a medical order or payment.

Immediately upon aproval, you will be contacted by a Registered Nurse (RN) to schedule your requested service(s)

Full Name

First Name

Last Name

Phone Number

(###)

###

####

Service(s) that you are interested in

Preferred appointment type

No fee for a virtual appointment

Brief Health History

Please include allergies, medications, and health goals (optional)

Preferred Appointment Date

YYYY

Consent

“I understand that all services require medical screening and provider approval prior to treatment. Submitting this form does not constitute a medical order or payment.”

I Consent

E-Sign

If consent is given, please E-Sign with your first & last name below.