PLEASE BE ADVISED THAT WEARE UNABLE TO BILL ANY INSURANCE ACCEPTED BY OUR OFFICE WITHOUT A COPY OF THE CURRENT INSURANCE CARD. Also, in the event your insurance company denies the claim for ANY reason, youwill be personally responsible for the charges incurred.
Assignment of Benefits: I authorize assignment of all medical insurance benefits to the named provider for the medical services rendered.
Assignment to pay for Services: I agree to pay Green Health Clinic for all charges for services rendered to the patient today, or any future date of service in the office. I understand payment in full and/or co-pay and/or co-insurance is expected at the time of services rendered. I further understand, in the event this account is referred to an agency or attorney for collection, I will be responsible for all collection fees, attorneys’ fees and/or court costs.
Having an active spiritualor religious life is an important part of overall health.
Describe your current religious practice (please provide details as to how often and what you do. For example, do you attend church or other ceremony? Any small group studies?)
Green Health Clinic believes very strongly that the food you put in your body plays a large role in your health; both positively and negatively. A food diary is a very valuable resource fordeterminingyourcurrentlevelofnutrition.Itwillallowustomakerecommendationsfor improvement, as well as consider the possibility of some groups of foods that may be causing symptoms.
Please choose two days to record all of your intake. These days should be considered "normal", don't choose days where your foods are drastically different from usual. Try to record intake for at least one weekday and one weekend day, because food choices can be different. This is preferred but not necessary.
Please list the reasons you have come to Green Health Clinic
