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I.V. Therapy Intake Form

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APPLICATION GUIDELINES & OFFICE POLICIES

Thank you for considering Whole Health Center Houston as your partner in healing and healthy living! Please submit this form to begin your journey of healing at Whole Health Houston. Feel free to call if you have any questions or if you would like clarification.

INSURANCE POLICY

Because of the nature and scope of our practice, we are a Direct-Pay practice and we DO NOT accept insurance. As a courtesy, we will provide you with a statement which is necessary for you to file an insurance claim with your provider.

Acknowledgment of Insurance Policy*

I understand that Whole Health Center Houston is "insurance-free."

Medicare and Medicaid Opt-Out

We have chosen to opt-out of the Medicare/Medicaid system, and therefore services provided by Whole Health Center Houston are not eligible to be covered by Medicare or Medicaid. If you are covered by Medicare or Medicaid, we will require that you sign the federally-mandated patient-doctor opt-out contract.

Acknowledgment of Medicare and Medicaid Opt-Out*

I understand that Whole Health center Houston has opted out of the Medicare program and that I cannot submit claims to Medicare or Medicaid for services.

MEDICAL HISTORY

The information we ask for in this form is to help us prepare for your visit and hopefully exceed your expectations. Please fill in this form as completely as possible.

Member Personal Information

First Name* Middle Name (or initial) Last Name* Date of Birth* Sex* Nickname/Preferred Name

Parent or Guardian

Primary person for discussing child's health information?

Relationship to Child

Contact Information & Communications

Email Address* Confirm Email Address*

Mobile Phone Number Home Phone Number * Work Phone Number Preferred Contact Number*

Address 1 * Address 2 City * State/Province * Zip Code *

Member Portal

To gain online access to your medical records and secure communications, please create a username and password password.

Your username must be at least 4 characters long

Username *

Your password must be at least 8 characters long and include at least one number or special character.

Password * Confirm Password *

Alternate Contact Person

Used in case of emergency or inability to contact primary person.

Contact's First Name* ... and Last Name* Alternate Contact Phone #*

How did you hear about us?*

Internet Search Word of Mouth Referred by Another Patient

Referrer Name

Other

Tell us more about yourself

Occupation Marital Status Hobbies: Faith/Religion:

Health History

To be sure that you are a good candidate for I.V. therapy, it is important that we know your current and past health conditions.

This health information is used only for our medical purposes and will not be shared with any third-parties without your permission. We do NOT use health status to determine fees or deny membership.

Current Medications

Please include any and all medications you are taking regularly or "as needed."

Medication name & details

If you are taking any of the below medications, please review our MEDICATION POLICIES to make sure Whole Health Center Houston is right for you.

Amphetamines (Ritalin, Adderall, Phentermine, etc.)
Opiates (Morphine, Hydrocodone, Lortab, Codeine, etc.)
Benzodiazepines (Lorazepam, Valium, Xanax, etc.)
Sleeping Medications (Ambien, Lunesta, etc.)

Current Vitamins, Herbs, or Supplements

Please include any and all vitamins, herbs, or supplements you currently use.

Supplement name & details

Reason For Wanting I.V. Therapy*

Please explain what condition you wish to treat with I.V. therapy, and why you feel that I.V. therapy is your best option.

Medical Diagnoses

List all medical conditions with which you have been formaly diagnosed, and the approximate month/year of your diagnosis.

Diagnosis

Your Goals and Questions

We want to fulfill your expectations, so please take a moment to tell us your primary goal and questions for your visit.

Please tell us your MAJOR GOALS.

What would you like to accomplish with I.V. therapy?

Goal*

Please tell us what QUESTIONS you would like answered during your I.V. consult.

Note: if you have any questions about our process for applications, or any other general question you would like answered BEFORE your first visit, then please call our office at 713-840-9355 or send us an email at GetWell@wholehealthhouston.com.

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