New Patient Intake Form

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Name*
Address*
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Phone Type
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Phone Type
Preferred Form of Contact*

REASON FOR VISIT

If you have multiple symptoms, feel free to list the duration for each one individually.

CURRENT HEALTH CONDITIONS

Include specialists, primary care doctors, or alternative therapists you’ve consulted regarding these specific concerns.
Briefly describe what was done (e.g., physical therapy, injections, surgery) and if it helped, worsened, or had no effect on your symptoms.
Please include the medication name, dosage (e.g., 20mg), and how often you take it.
Many natural supplements can interact with treatments; please list everything you are currently taking.
Please include minor procedures and any hardware (stents, pins, or plates) currently in your body.
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Accepted file types: jpg, pdf, png, Max. file size: 20 MB, Max. files: 10.
    DISCLAIMER*

    CONSENT TO PAYMENT

    I understand that all services are rendered on a cash, check, or credit/debit card basis. I agree to pay for each appointment at the time of service and accept responsibility for any debts incurred.
    Name*

    CONSENT TO EXAMINATION AND TREATMENT

    Dr. Brian Klepzig utilizes advanced Energy Medicine to evaluate functional health conditions. These techniques, including Applied Bio-Energy Analysis (ABEA), are used to assess wellness and do not diagnose pathological medical diseases. I hereby give permission for the doctor to perform such procedures and treatments as deemed necessary for my condition.
    Name*

    NOTICE OF PRIVACY PRACTICES

    Protecting the privacy of your personal health information is important to us. This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Disclosure of your protected health information without authorization is strictly limited to defined situations that include emergency care, quality assurance activities, public health research, and law enforcement activities. Any other disclosures for the purpose of treatment, payment, or practice operations will be made only after obtaining your consent. You may request restrictions on disclosures. This provision does not apply to the transfer of medical records for treatment. Disclosures of protected health information are limited to the minimum necessary for the purpose of the disclosure. We maintain a history of protected health information disclosures that is accessible to you. You may inspect and receive copies of your records within 30 days of a request to do so. There may be a reasonable cost-based fee for photocopying, postage, and preparation. In the future we may contact you by mail, email, or telephone for appointment reminders or announcements. Our practice is required to abide by this notice. We have the right to change this notice in the future.
    Name*
    Date*