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The Churchill Center Intake FORM
Welcome. This simple form is the first step to achieve your aspirational health and wellness goals. Whether your journey is improving body image, life long optimal health, rejuvenation, healing or something so intimate that you need a trusted soul to share with. So sit back. take a calming breath, tune into your online music station and take 15 minutes or less to begin anew. Dr, Dana Churchill is looking forward to gaining insights into how you may become a healthier and happier you!
This information is strictly and respectfully confidential.
Beginnings are always a bit daunting, if not frightening. Trust that Dr. Dana is here to support you in your time of transformation toward optimal health for a lifetime. Please read through our policies and treatment plans carefully before submitting this form.
If you do not finish the Q&A in one sitting it automatically SAVES , so you may return at your leisure.

Email address *
The Churchill Center for Integrative Medicine - Rejuvenation - Aesthetic & Inner Beauty. Concierge Care throughout Southern California and Beyond.
Dr. Dana Churchill - City Club - Los Angeles October 27, 2018 reviews a patients initial blood work, disposition, aspirations and goals to arrive at a balanced diagnosis and treatment plan.
Today's Date: *
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Name: *
First Name Last Name
Date of Birth *
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What Age Do You Feel? *
Gender Orientation *
Occupation - Profession - Avocation - Creative Outlet
Hours per week:
Employer - Self Employed -Sole Owned Business
Are You Single? Committed Relationship? Family?
Who is your closest and trusted contact?
Home Address: *
City: *
State: *
Zip Code: *
Home Phone:
Cell Phone: *
Email: *
Emergency Contact Name:
Emergency Contact Number:
PPO OUT OF NETWORK INSURANCE CLAIMS MANY TIMES GET REIMBURSED FOR TREATMENTS, CONSULTS AND LABS.
FOR INSURANCE CLAIMS TO BE SENT FOR YOU, YOU MUST FILL OUT:
Social Security Number:
Driver's License Number
Driver's License State:
Please have your insurance card ready for us to make a copy. Or email a scanned copy to: drdana707@gmail.com.
How did you hear about The Churchill Center?
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