Welcome to Whole Health Center Houston's Patient Portal

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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

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 Vitamins, Herbs, or Supplements

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

Supplement name & details

Nutrition Summary

Please list your major nutritional concerns and problems

What is your nutritional concern/problem?

How long have you had this problem?

What, if anything, makes it better?

What, if anything, makes it worse?

What tests or exams have you had done for it?

List any medications and/or supplements you have taken specifically for this condition?

Please tell us what QUESTIONS you would like answered by Erin during your first visit.

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.

Question

Running/treadmill	Bicycling
Swimming	Dancing
Sports	Strength training
Yoga	Pilates
Other

Peanut	Tree nuts	Milk
Egg	Gluten	Soy
Fish	Shellfish	Other(s)

Pollen	Cat	Dog
Insect sting	Mold	Latex
Cosmetics	Other(s)

Go to...

Nutrition Intake Form