Client Follow-up Visit Form

For new or follow-up visits, and pH Review and Balancing, please avoid eating, drinking, smoking, or placing gum, mints, toothpaste, candies, or any other items in your mouth at least 2 hours before your appointment.

Please do NOT wear or apply any scented perfumes, colognes, soaps, oils, sprays, clothing, or other products on the day of your appointment for the health and safety of our clients and all those involved in your care.

Please fill out the document to the best of your knowledge and make every effort to submit your completed document to the practice before your scheduled appointment using this website, emailing, or printing it.

You can download the Follow-up form using the button to the left or fill it out online below.

Name

Address

City

State

ZipCode

Phone:

Complaint

Agreement Terms

I understand that I am here to learn about nutrition and better health practices and that I will be offered information about food supplements, herbs, exercises, and lifestyle alterations or maintenance as a guide to general good health. I fully understand that those who counsel me are NOT medical doctors, and I am not here for medical diagnostic purposes, or medical treatment procedures. I am free to apply the information, guidance, and products received from this practice and its personnel to my benefit or choose otherwise. I am not on this visit, or any subsequent visit, an agent for federal, state, or local agencies or on a mission of entrapment or investigation. The services performed here are at all times restricted to consultation on nutritional matters, exercises, or lifestyle alterations intended for the maintenance of the best possible state of natural health, and do not involve the diagnosing, treatment or prescribing of remedies or medications for a disease of any type. I attest that I have answered any and all questions to the best of my ability in all honesty for review and will not hold liable any and all parties associated with the practice listed on this form or its affiliates for outcomes resulting in contrast or adversity due to the omission or incorrect answers to said questions presented to me on this form. The answers to these questions presented to me and any information given to me by this practice and its personnel during my initial consultation, standard appointments, follow-up appointments, scheduled sessions, or approved meetings, be it in person or virtual, will remain under the doctor to client privilege relationship thus completely confidential between parties and will not be shared with any individual that is not duly authorized by the practice and its personnel and myself. You have reviewed and agreed with the terms of the form. By checking this agreement to terms box and typing your name on the Signature line below, you are signing this agreement electronically. You agree that your typed signature is the legal equivalent of your physical signature on this form. By checking the agreement to terms box and typing your name on the Signature line you consent that you are authorized to act on behalf of yourself or the person to which you are legal guardian to the terms outlined on this form and you consent, on behalf of yourself or the person to which you are legal guardian, to be legally bound by the agreement and all its terms and conditions.

Signature

Date

Client Follow-up Visit Form

For new or follow-up visits, and pH Review and Balancing, please avoid eating, drinking, smoking, or placing gum, mints, toothpaste, candies, or any other items in your mouth at least 2 hours before your appointment.

** Please do NOT wear or apply any scented perfumes, colognes, soaps, oils, sprays, clothing, or other products on the day of your appointment for the health and safety of our clients and all those involved in your care. **

Please fill out the document to the best of your knowledge and make every effort to submit your completed document to the practice before your scheduled appointment using this website, emailing, or printing it.

You can download the Follow-up form using the button to the left or fill it out online below.

Please do NOT wear or apply any scented perfumes, colognes, soaps, oils, sprays, clothing, or other products on the day of your appointment for the health and safety of our clients and all those involved in your care.