New Patient
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Name: *
Address:
Telephone:

Email:
Date of Birth

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Sex
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Marital Status
Number of Children
Height
Weight
Occupation
Health Concerns?
Vitamins, Supplements, Medications you are taking
Medical History
(List any major illnesses, injuries and/or surgeries that you have had and when)
Allergies:
Do you have amalgam fillings? If yes how many?
Do you have root canals?
Eating habits and Food intake:
Hobbies, habits and interests:
Do you exercise? If yes how often and what do you do?
Do you smoke?
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If yes, for how long, how many/often?
Do you use recreational drugs?
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If yes, which ones? Frequency?
Rate your energy
lowest
highest
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Rate your stress
lowest
highest
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How many hours of sleep do you get on average?
Do you wake up during the night at all?
Do you feel refreshed in the morning?
How frequently do you move your bowels?
Female Reproductive
Age of your first menses:
If menopausal, age of last menses:
How long does your menses last?
How long is your cycle?
Do you experience any of the following:
Anything else to note about your period:
Are you sexually active?
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Do you use contraception? If so what form?
Male Reproductive
Frequent or difficulty urinating?
List any concerns here:
Anything else you'd like your practitioner to know?
Payment Responsibilities:

I AGREE to pay my full account at the time of each visit or treatment, including fees for services and cost of remedies.

All 50 minute appointments: $130

New Client (75 minute) appointments: $160

Cash~Check~Venmo~Credit Card ($5 surcharge)

Rick Does not accept insurance at this time. 

Notice of 48 hours is required for appointment cancellation. If canceled between 48-24 hours, you will be responsible for half ($65). Within 24 hours the patient will be charged for the full cost ($130).

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Date:
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Signature (type full name) 
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