New Client Questionairre

New Client Intake Form
Client's Name*
Today's Date*

MonthDayYear
Age*
Date of Birth*
Street Address*
City*
State*
Zip Code*
E-mail*
Home Phone Number*
Cell Phone Number*
Parent's Names (if child)
Who can we thank for referring you?*
Chief Complaint-What is the reason you are seeking care?*

Please list your major problems and/or symptoms and the approximate date the symptoms began. If symptoms are associated with a particular event (i.e. vaccine, illness, accident, etc.) please indicate.*
What do you believe caused this condition?*
Please list any previous interventions (supplements, modalities, medications) that you have tried and their relative success. What worked for you and what didn't work?*
Please give a detailed account of your medical history. Be sure to include and surgeries, diseases, hospitalizations, or major medical incidents, along with medications prescribed if possible. If you have any areas with scaring, please indicate.*
For children, please give a detailed account of pregnancy and birth. Please indicate if your child was a vaginal birth or C-section, whether or not mom took any medications during pregnancy or birth, etc. Please give a detailed account of infancy and early childhood. Was your child breastfed? Did he/she meet expected milestones? Did your child experience and recurring illnesses (croup, ear infections, strep, etc)? Did your child receive antibiotics?
Please list any vaccines that you or your child have received along with dates and reactions, if applicable.*
Have you experienced any environmental exposures that you are aware of? Do you or did you ever live near a non-organic farm, chemical plant, factory, mobile phone tower, high-power generator or power line, nuclear power plant, golf course, or a highway?*
What is you occupation?
Please describe yur dental history if applicable. Did you or did you ever have silver fillings, root canals, extractions? If you had your silver fillings removed, did you go to a biological dentist?*
FAMILY MEDICAL HISTORY: please list any family physical or mental illnesses and age of death if applicable. Please indicate if any close family members have allergies, eczema, Alzheimer's, asthma, ADHD, Lyme, Autism, PANS/PANDAS, MS, Cancer, RA, thyroid disorders, etc.*
Please list any foods that you avoid/dislike or have sensitivities/allergies to:*
Are you on a special diet?*
Please list any environmental allergies/sensitivities that you are aware of:
What changes would you like to see in your health in the next six months?*
What obstacles do you see in reaching your desired level of health and vitality?*
What is the most important health change you would like to occur?*
When were you last seen by your doctor?
Doctor's Name:
Doctor's Address:
City, State, Zip:
Speciality
Diagnosis by Doctor
Please describe any lab work you have had done.
Please list all medications you are presently taking:
Please list all supplements, herbs, and over-the-counter drugs you are presently taking:
Please list current therapies if they are applicable to your condition.

Release Agreement
I am requesting CornerStone Integrative Care LLC to provide the following services to my child/self *

BioSET Bioenergetic Sensitivity and Enzyme Therapy, $250 for the initial 1 hour visit, $125 each 1/2 visit thereafterHomotoxicology Treatments/ZYTO $250.00 each 1 hour visit + SupplementsVitamin, Enzyme, Nutritional Therapy (product list available for pricing, subject to 6.35% tax)Non-client Supplement Ordering Through Our OfficeMultiple services, to be determined by the practitioner with pricing aboveOther
I Agree to the Following:
1) I understand that I am advised by CornerStone Integrative Care LLC that it is necessary to communicate my intentions to participate in this program with my physician, describing its various components with my physician, and will obtain permission from said physician prior to receiving these services. If my physician is of the opinion that participation in this program offered by CornerStone Integrative Care LLC will aggravate any symptoms, illnesses or disorders which my child/self may have, or will it be harmful, injurious or detrimental to the health, safety or well-being of my child/self I will not participate in this program.

2) I warrant and represent that my child/self is (are) in good physical and mental health and have no ailment, disability or impairment which might prevent him/her/myself from receiving these services or which might be aggravated or activated by such services.

3) I am aware that each human body is different structurally and bio-chemically and will react differently to the services provided. Accordingly, there is no certainty or predictability as to how my, or my child's body, might react. I acknowledge that I am participating in this program of my own free will. CornerStone Integrative Care LLC has not made any claim, promise or guarantee regarding the effectiveness, usefulness, performance or safety of this program.

4) I understand that the services provided by CornerStone Integrative Care LLC are not a substitute or alternative to medical care. I retain the responsibility for ensuring that my child/self is under the regular and continuous supervision of a licensed physician.

5) I am aware that under no circumstance will the services provided by CornerStone Integrative Care LLC diagnose. treat, operate on or prescribe for any disease, pain, injury, or physical condition. Only a licensed physician may engage in such activities.

6) Costs for the services, therapy, supplements of the program have been disclosed to me. I understand that all prices are subject to change, I have been notified that any costs involved by CornerStone Integrative Care LLC will NOT BE COVERED by medical insurance and that no medical or insurance coding will be provided on any invoices.

7) CornerStone Integrative Care LLC will accept vitamin/supplement returns within 30 DAYS of purchase provided they are unopened and in good condition. However, IMPRINTED ITEMS CANNOT BE RETURNED.

8) I understand that payment is due within 30 days unless other arrangements have been made

9) 24 Hour cancellation notice miust be made in order to not be charged for the appointment. Exceptions can be made for emergencies only. A 50% cancellation fee will be applied for missed appointments.

10) I am aware that these services require that I provide confidential health information regarding my child/self to CornerStone Integrative Care LLC and any affliliated health care practitioners within the practice.

11) I acknowledge that I have evaluated the advisability of my child's/own participation in the program provided by CornerStone Integrative Care LLC. I, in turn, take full responsibility for the physical, mental and emotional transformations attained as a result of such participation. In consideration of CornerStone Integrative Care LLC's consent to allow my child/self to participate in the program, I hereby agree for myself, my heirs, and assigns to hold CornerStone Integrative Care LLC harmless for any and all liability arising out of my child's/own participation in the program or receipt of any services. I take full responsibility for any and all injuries or losses, and freely, knowlingly, and voluntarily agree to assume all risks involved, if any, during the program.
BY ACKNOWLEDGING AND SIGNING BELOW, I AM AGREEING TO THE ABOVE ELEVEN POINTS AND DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
CLIENT SIGNATURE*

Should be Empty:

I Agree to the Following: