Mountain State Wellness

Office Forms

 

Dear Prospective Members,

We desire for your visit to our office to be convenient and time efficient.  If you would prefer to complete the following forms prior to arriving at our office, you are welcome to do so.  Please remember when completing the “Health History Forms” that the doctor needs as much detail as possible to provide the most appropriate and best care for your situation.  We thank you for investing your time into this necessary step of your care.  We appreciate your efforts, respect your time and anticipate the opportunity to help you and your family!

Doc    Adult Health History Form: All prospective members 13 years old or older should complete this form.

Doc    Child Health History Form: All prospective members 12 years old or younger should complete this form.

Doc    Nutrition Survey: All prospective members should complete this form prior to beginning our care.

Doc    Toxicity Questionnaire: All prospective members 13 years old or older should complete this form. 

Doc    Terms of Acceptance Form: All prospective members should complete this form prior to beginning our care.

Doc    Privacy Notice for MSW: All prospective members should READ this form prior to beginning our care.

Doc    Signature Page Privacy Notice for MSW:  All prospective members should PRINT and SIGN this form after reading the privacy statement prior to beginning our care.