Patient intake form

Upon your visit please provide us with a copy of a current state photo ID

I attest that the information provided above is true and correct to the best of my knowledge and that I am responsible for payment of all charges and that payment is required at the time of service, unless previous arrangements have already been established. I authorize the release of any medical or other information to process claims on my behalf. I understand that my insurance policy is an agreement between me and my insurance company and reimbursement from my insurance company is their legal obligation to me.

TO HELP US GATHER DATA FOR RESEARCH, PLEASE ANSWER THE FOLLOWING QUESTIONS IF YOU HAVE PREVIOUSLY PARTICIPATED IN THE RESEARCH PROGRAM

CONFIDENTIAL HEALTH QUESTIONAIRE

Instructions: Select the number which best describes the intensity of your symptoms.
If a question does not apply to you, leave it blank.
1=Mild, 2=Moderate, 3=Severe

MEN ONLY

WOMEN ONLY

Instructions: Select only those that apply to you and/or your health condition

I have answered the above questions to the best of my knowledge.

DECLARATION ON INFORMED CONSENT TO SERVICES

I understand and acknowledge that (i) Dr. Colby Inzer, KLJ, ND (ii) Dr. Corrine Inzer, DLJ, DMM and (iii) all independent contractors of Pressing Matters Mechano Therapy & Naturopathic Health (collectively defined as “Pressing Matters”) offer no guarantee that the treatments will cure me of any disease or affliction (including cancer). I believe it is within my constitutional rights to seek any form of diagnosis and treatment, whether orthodox or unorthodox (i.e., not recommended by the AMA). It is my choice whether or not to accept such diagnosis and treatment. By my signature, I attest that I have not engaged the service of Pressing Matters for the purposes of filing a malpractice suit or furthering any investigation or prosecution by any government entity or medical association. My sole purpose and intent in seeking the services of Pressing Matters is to get help for my personal health matters.

I understand that Pressing Matters’ treatment program includes Naturopathic Treatments, Reflexology, Mechanotherapy, Acupressure, Applied Kinesiology, Spinal Touch, Nutritional Guidance and Counseling. I also understand that the treatment may be unconventional or experimental. In such case, I agree to hold Pressing Matters harmless if the results of the treatments are not what I hoped for.. I acknowledge that my acceptance of their services binds me to pay the fee and that such fee reflects their knowledge, education and years of experience.

Payments for services are due at the time service is rendered, unless payment arrangements have been approved in advance by our staff. We accept cash, checks, MasterCard, Visa, Discover, or American Express.

I understand that I have the right to choose the doctor of my choice to provide services. I also have the right to discontinue the care and treatments of that doctor at any time, but agree that I will promptly pay to date any outstanding balance due for the services. I also acknowledge that I have not been advised against seeking any other medical examinations or treatments.

I understand that Pressing Matters does the (HLB) DBA/LBA blood research comparison appraisals. This is used to help gather data for future reference and assessment using this type of test. The DBA detects morphological changes which show pathological conditions. However, many of these morphological changes appear similar, particularly in early stages. Therefore, a definitive diagnosis is not possible with the DBA/LBA blood appraisal alone.

If you wish to participate in the blood appraisal comparison program, it will be necessary for you to fill out completely the Confidential Health Questionnaire. An assessment will not be done without the Confidential Health Questionnaire and/or a comparison modality (such as conventional medical reports or lab work). There is an $125.00 fee to analyze the questionnaire and/or conventional medical reports and write a suggested nutritional program for you. We may also give you a prescription to have other conventional tests done if desired or needed to assist with the comparison and assessing of your health condition.

I have read (or have read to me) the Declaration of Informed Consent to Services and agree to be bound by the terms therein. I have not signed this declaration without first reading it or having it read to me and I may ask any questions useful in helping me understand it. I further understand my agreement to the provision of this declaration is an entirely voluntary and informed choice to which my signature attests.

Cancellation Policy

Appointments must be cancelled 24 hours in advance. If an appointment is cancelled less than 24 hours in advance, and we are unable to fill your appointment time, or the appointment time is forgotten (patient does not come in or call), there will be no charge the first time. After that, the normal fee will be charged.