New Patient Forms | Winters Wellness Center of PaducahNew Patient Forms

HOLIDAY NOTE:

We’re out of the office starting Dec 26th and will return on Jan 2nd. We will respond to your message when we return and in the order in which it was received. Happy Holidays!

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NutritionOrder Supplements

Directions4965 Village Square Drive

Call270-554-2141

New PatientsGet Started

Latest VideosOur YouTube Channel

NutritionOrder Supplements

Directions4965 Village Square Drive, Paducah KY 42001

Call270-554-2141

New PatientsGet Started

New Patient Forms

Winters Wellness Center
New Patient Forms

Personal Information

Full Name *

Email *

Do we have your permission to send you information from the practice via email? *

Phone *

Address

City

State

Postal code

Birth Date *

Current Age *

Biological Gender

Marital Status

How did you first hear about our office?

Please list your top five health concerns or primary reasons for visiting our office. *

What would optimal health look like for you? ( ie: What would you be able to do, experience or feel differently ) *

What are the life goals that optimal health could assist you with? *

How much time have you spent with our website, Facebook page, YouTube channel or talking to friends about our office?

In helping you solve problems and reach optimal health we work thru HIDN®. HIDN® involves Hormonal balance, Immune strength, Detoxification efficiency and Neurological connection. We are proud that HIDN® is unique enough to be awarded a US trademark. The next slides will have questions related to these topics.

Hormonal balance:

Please describe the timing and ease with which you get to sleep and stay asleep, if you snore, if you wake feeling rested and if you use any sleep aids.

Does your energy fluctuate during the day and does it change with eating? When is it best and worst?

Ladies - Please describe any issues with hair loss or hair growth, low or excessive sex drive, temperatute changes ( cold, hot, hot flashes ), changes in breast tissue, changes in skin or vaginal dryness

Ladies please describe cycle regularity or lack thereof, any ovaries removed as well as current and past history of birth control.

Ladies : Please describe number of pregnancies ___, live births___ ages of children ________miscarriage or abortion history ____

Men - Please describe any prostate problems, erectile difficulties, increases in belly fat or decreases in muscle mass and increases or decreases in sex drive.

Please describe any heart palpitations, ringing of the ears, changes in pulse, skin, temperature or weight

All please list any hormone supplements, patches, creams, pellets or injections that you receive

When and where were your last set of labs completed?

Immune strength :

Is there any family history of autoimmune conditions? (thyroid disease, Hashimoto's or Graves, Celiac Disease, MS, Lupus, rheumatoid arthritis, type one diabetes etc.)

Please estimate antibiotic use in childhood and adulthood

Describe any recurrent infections or fevers

History and Dates of Any COVID-19 Infection or Vaccines

Describe any vaccine reactions (COVID-19 or otherwise)

Describe any tick bites or other bites or diagnosis or suspicion of Lyme disease

Describe any possible or known exposures to mold

Describe any known or suspected environmental or dietary allergies or sensitivities

Describe any issues with bloating, burping, belching, indigestion, stomach or abdominal cramping, constipation or diarrhea or other digestive or abdominal concerns

Detoxification efficiency :

Please list all of your current medications and the reason for taking each

Please list all current supplements

Please list your current use of tobacco, alcohol, coffee, soda,energy drinks, artificial sweeteners, marijuana and recreational drugs

Please list past usage and time frames of alcohol, marijuana, and recreational drugs

Please list number of non tooth-colored fillings, number of root canals and any dental implants or fixtures both present and in the past

Describe any significant exposures to paint, polishes, bleaches, disinfectants, perfumes, hair sprays, cosmetics, exhausts, gas or diesel fumes

Describe any health changes after moving to a new home or taking a new job

Patient’s Responsibilities Policy

1. If you have any updated information since your last visit (such as, change in name, address, phone number, or insurance) please notify the front desk staff when you arrive for your appointment.

2. Self-pay patients are required to make payment arrangements or pay in full on the day of your office visit.

3. If you have a previous balance on your account, you must pay this amount or make payment arrangements before your office visit.

4. You agree, in order for us to serve your account, notify you of information pertaining to your account, or for the purposes of collection, that we may contact you by telephone at any number provided by you including wireless telephone numbers. Methods of contact may include the use of pre-recorded and artificial voice messages, text messaging and/or use of an automated dialing service.

5. Any appointments that are not cancelled before 24 hours of appointment time, will be billed to patient account at 50% of the service fee. If you miss an appointment and do not contact us prior to that appointment, you will be billed at 100% of the service fee.

6. We know the body has an incredible ability to heal itself if there is no neurological interference . We are constantly investigating the newest and most powerful techniques in healing which allow us to get results that many rave about and produce five star reviews and testimonials. This same drive to investigate the best skills and tools for our patients leads to insurance companies labeling what is not standard as investigational and thus not covered . We are therefore not in network with any insurance companies, nor do we write any medical reports.

7. All new patient consultation and exams , reports of findings and Quantum Neurological Reset Therapy and any financial discussions will take place in a private room . Spinal adjustments and therapies may be in an open room . There is a synergy of people and their healing experience in an open room that actually accelerates results. If we sense you need more privacy , your care requires it or you ask for it we are happy to move you to a private room . We have many allergy sensitive patients so we have a minimal fragrance policy. We also ask that your cell phone be in airplane mode while in the office as many times we are doing eeg's that the wireless signals can interfere with. If there is a circumstance your phone has to be on please refrain from talking out loud on your phone as this distracts from the healing environment. In general we ask that those with appointments wait in the center of the office for care to begin and those who accompany you wait in the lobby area.

HIPAA Notification

Pursuant to HIPAA regulation, for any of our patients over the age of 18, we are unable to give any information, whether medical or financial, to any family member. This includes information about your spouse or your child, 18 years of age or older. Please read below and consider carefully who you want to have access to your medical/billing information.

I give Winters Wellness Center permission to leave phone messages regarding my medical care and/or lab results at the following numbers. My medical care/billing account may be discussed with the person(s) listed below.

We will not leave messages with anyone except the patient or legal guardian. We will not leave any information on an answering machine. We will not leave messages on a voicemail unless we have your written permission to do so.

1. How We Leave Messages: I give permission to leave phone messages on (check all that apply):

a. My cellular phone voice mail

b. My home phone answering machine

c. My office/work voicemail

2. I give permission for the following people to have access to my records: (please type their name, relationship to you, and contact number)

Notice of Privacy Practices

I have read, understand, and agree to the Notice of Privacy Practices for protected health information that was provided to me by Winters Wellness Center.

MEDICARE/INSURANCE uniform of assignment, release of information and financial disclosure

MEDICARE ASSIGNMENT OF BENEFITS: I hereby assign or transfer payment benefits made to me and my behalf to Winters Wellness Center for any services furnished to me by this facility. I further agree that I am responsible for payment or charges incurred by me that are not covered by my insurance or for which my insurance has paid me.

RELEASE OF INFORMATION: I hereby authorize Winters Wellness Center to release information acquired during the course of my examination or treatment to my primary care doctor or to an appropriate insurance carrier. If Medicare patients, I further authorize release, of the Center of Medicare Services and its agents, any information needed to determine benefits payable for related charges.

PERMISSION TO CONTACT: I hereby authorize Winters Wellness Center to use the provided contact information to send me personal messages and messages intended for all patients, current and previous to the practice, including - but not limited to - upcoming event announcements, practice closure alerts, and other information.

New Patient Acceptance Signature *

Clear

I, the undersigned, agree to all of the policies provided to me at this time.

Terms and Conditions