New Patient Intake Form

What is your gender? *

Marital Status: *

Is this your legal name?

Yes

If not, what is your legal name?

Referred to clinic by: *

Dr. Referral

Family/Friend

Dinner Event

Has power of attorney been assigned that limits your ability to make your own decisions while conscious? *

Yes

Who in your family is involved in your health decisions? (Daughter, Son, Spouse, etc..) *

We often find our patients have the desire to help others suffering from nerve damage. List other family members / friends who's lives would improve with understanding of their condition.

Name & Phone
Name & Phone
Name & Phone

General: (check all that apply)

Fatigue, Tiredness

Weakness

Sedentary Lifestyle

Generalized Pain

Neurological: (check all that apply)

Endocrine: (check all that apply)

Thyroid Problems

Diabetes - Type 1

Diabetes - Type 2

Pre-Diabetic

Vascular: (check all that apply)

Musculoskeletal: (check all that apply)

Arthritis

Muscle Weakness

Fractured Back or Neck

Check Areas you have experienced Pain, Numbness, Tingling, or Stiffness in the last 6 months: (check all that apply)

How would you rate your average pain over the past week for this problem? 0 No Pain - 10 Worst Possible Pain

CANCERS: Have you had any cancers?

Yes

If yes, please list All Cancers and for how long

Height & Weight:

Height: Feet
Height: Inches
Weight: Ibs

Please list any prescribed medications you take:

Name + Dosage
Name + Dosage
Name + Dosage
Name + Dosage
Name + Dosage

Do you have any allergies to medications? *

Yes

Please list any allergies you have to medications:

What is your major complaint? *

How long have you had this problem? *

Before you began having this problem was there an earlier condition, accident, or injury that could have brought this problem about? *

Yes

If so please describe:

What have you tried for treatment that did not work? *

I hereby acknowledge that the information contained in this form, including contact information, medical history, and diagnosis, is correct as of the time of signing. I understand that it is my responsibility to report changes in information, history and diagnosis at least 5 business days prior to my appointment. *

Agree

I hereby acknowledge that no guarantees have been made and that the practice of regenerative therapy is not an exact science and that the therapy may involve risks. I acknowledge that this procedure is considered elective and not medically necessary. No outcome may be the result of the therapy. *

Agree

I hereby acknowledge that no employees or contractors of Amplified Wellness are to be considered my primary care provider and that the care provided is limited to the areas listed above in this agreement. *

Agree

I hereby acknowledge that this therapy can be rescinded, for a full refund, within 3 business days of signing this agreement. Refunds will be sent within 10 days. *

Agree

I hereby acknowledge that this therapy can be canceled up to 7 business days prior to the scheduled appointment in writing. If this is the case, I understand my refund will be processed within 30 days of receiving cancellation request. *

Agree

I understand that if I cancel within 0-7 business days of my appointment, I will be responsible for the cost of materials and other costs associated with the late notice cancel. *

Agree

I hereby acknowledge that if 12 months following therapy, I am not at least 50% improved in the area therapy was administered and have followed the protocols given to me for my success, RenewWell will provide an additional therapy session at an 80% discount. *

Agree

I hereby acknowledge that this agreement goes into effect when RenewWell receives payment. *

Agree

I agree and understand that this agreement constitutes the entire understanding between the parties, and that there are no verbal understandings changing or modifying any of the terms of this agreement. *

Agree

I hereby agree to receive calls, text messages and emails from RenewWell. *

Agree

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

For Office Use Only:

Treatment Areas:

Shoulder
Elbow
Hand/Wrist
Hip
Knee
Foot/Ankle

Special Instructions:

Method Of Payment:

Credit Card

Check

Financing

Credit Card #:

*100% secure & safe payments* By entering credit card information above, Customer(s) hereby authorizes RenewWell to charge the credit card as indicated. PLEASE VERIFY THAT DAILY AND SPEND LIMITS ARE NOT EXCEEDED.

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