Educational Consultation
Integr8 Health educational consultation intake form and consent
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Email *
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Full Name of the person with conditions you are getting an education consultation for  *
Date of Birth  *
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Phone number  *
Address  *
City *
State *
Zip Code *
Weight 
Are you qualified to access medical cannabis in your state? *
Please describe your goal(s) for this educational consultation: *
Please list any specific questions you have for your medical cannabis educator: *
Please list all of your current medications, supplements, and herbs (with dosages): *
Please list any allergies (medications, food or environmental, & your reactions): *
Are you established with a local medical provider who oversees your use of cannabis? *
Are you currently using cannabis? *
Please describe your current cannabis dosage and delivery method (for example, 2 puffs of THC-dominant smoke twice daily from a pipe, 40mg CBD oil in the AM and 10mg THC oil before bed, vaporized cannabis flower spread throughout the day averaging 4 grams per week, over the counter CBD oil 10 drops three times daily, etc.). Please be as specific as possible. *
What products are you using? Please include label information (feel free to send a link to a product website, photo of the product label, etc.): *
How does cannabis help you? *
In your experience with cannabis, what has worked well, and what hasn’t worked well? *
Have you had any negative effects from cannabis?
Medical History: 
We are willing to review pertinent medical records prior to your consultation, but this is not required. Please feel free to provide any information about your current medical situation and medical history.
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Electronic Signature Disclosure and Consent:

By selecting the “I agree” button, and/or entering your name, I am signing this document electronically.
I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. 
By selecting “I agree” using any device, means, or action, I consent to the legally binding terms and conditions of this document. 
I further agree that my signature on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement.

 If I am signing this document on behalf of a minor, I represent and warrant that I am the minor’s parent or legal guardian. 

I may decline to electronically sign this document and withdraw my consent to sign this document electronically by contacting the signature requestor directly, which may delay transactions. 
I may contact the signature requestor separately to request to sign this document on paper or to receive a paper copy of the signed document. 
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Consent to Health Education: 

I (the “Student”) am requesting Dustin Sulak, D.O. or another Integr8 Health medical provider (the “Teacher”) to provide personalized education via a phone or video chat. In no way is the Teacher creating a physician-patient relationship, and all communication provided is purely informational and not to be viewed as professional medical advice, nor is the Teacher providing the student with either diagnosis or treatment recommendations. The student is encouraged to seek out a physician licensed in his/her state for medical care regarding the use of cannabis. The communication the Teacher provides does not in any way imply the legality of the use of cannabis for medicinal purposes or otherwise within the student’s home state, nor advocate its use by that individual. I understand that cannabis is not approved by the Federal Food and Drug Administration for medicinal purposes and may contain unknown quantities of active ingredients and may potentially contain contaminants and/or impurities. I understand that the Teacher may not be knowledgeable of all the associated risks involved in the use of a non-FDA approved substance such as cannabis. I acknowledge that there is controversy in the medical/scientific literature available regarding the usage of cannabis and that more research is currently being conducted. I understand that my state may or may not allow for the legal use of cannabis, its use is not approved under federal law, and that the current and future enforcement action of federal law enforcement officials is uncertain.
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By entering your first and last name, you are providing your electronic signature indicating that you agree with the above education visit consent. (If the patient is under 18, their legal guardian should be the one to sign the form providing consent.)
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Payment  Policies

Payments are due at the time of visit.

This is crucial for us to offer independent medical care. We work for our patients and not for insurances, pharmaceutical companies, or the government.

We require payment information be provided at the time of scheduling.

You will be charged after your appointment.

All visits 90 minutes or longer require a 50% deposit at the time of scheduling.  This deposit will be credited to your visit.

If you miss a confirmed appointment, or cancel less than 48 of our business hours in advance (Mon-Thurs, 9am-5pm), this deposit will not be refunded.

For patients with a past due balance, we require consistent monthly payments with a minimum of 1/6th of their past due balance as well as paying for all future services at the time of scheduling, unless another payment arrangement has been made with our practice manager.

Late fees:  If your balance is over 30 days late, a flat $25.00 per month will be charged until balance is paid in full.

If you need to be seen but cannot afford to pay for a visit, please contact our practice manager to make a payment plan.

Our rates are:

o   Dustin Sulak, D.O - $400/hour

o   Danielle Saad, D.O  -  $300/hour

o   Arianne Kryskow, FNP - $300/hour

o   Shawn Sulak, DN - $125-200/hour

o   Visits can be scheduled in 15 minute increments.

Missed appointments and late cancellations:

All appointments that are missed or canceled within 48 of our business hours (Mon – Thurs) will be charged 50% of the visit cost.

After missing or late canceling 3 visits, patients will be required to pay in full at the time of scheduling.

Superbills

We do not contract with any insurance plan or bill insurance on your behalf.

We can supply you with a “superbill” or receipt with medical codes that you can submit to your private insurance carrier for reimbursement as an “out of network” provider visit.

Medicare or Mainecare do not reimburse for any “out of network” providers.

Reimbursement depends on your individual plan and we make no guarantee of payment or reimbursement by your insurance carrier.

Please request a superbill at the time of your appointment.

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