SATORI INTEGRATIVE MEDICINE CLINIC | PATIENT TOOLS
Welcome to Satori Integrative Medicine Clinic. We are honored to be part of your personal journey towards hope, health and happiness. As you prepare for your healing experience, please review the following forms and complete them prior to your first visit. If you prefer, you may pick up these forms at our office, and we are happy to help you fill them out. The patient information forms must be completed and delivered to our office prior to scheduling your first appointment. We will gladly accept any forms by fax at 970-832-0808 or email at firstname.lastname@example.org.
PATIENT INFORMATION FORMS:
We need these forms to schedule an appointment for you. Contact and Medical History help us know you better. For Ketamine infusions and most other services, we require you have an established relationship with a healthcare provider, and the Acknowledgement of Ongoing Care form is required in that case.
Patient Contact Form
Please provide us with basic contact information.
Medical History Form
Please allow 30-60 minutes to complete this form. It provides us with details necessary to provide you with the best care possible.
Acknowledgement of Ongoing Care
Please have your primary care or referring provider complete this form.
Advanced Beneficiary Notice of Noncoverage (ABN)
If you are on Medicare, please complete the ABN form as well—we do not accept or bill any insurance, including Medicare.
These are our office policies. We require signed copies to provide treatment. Please fax or email completed forms prior to your first visit or bring them with you.
Information about how your personal data will be stored and secured.
Payment & Cancellation Policy
Please review and agree to the terms of our payment & cancellation policy.
Consent to Electronic Communications
Please complete information we need about electronic communications.
OTHER USEFUL DOCUMENTS:
Ketamine Treatment Consent
Review this document if you are undergoing ketamine therapy. Your physician will review this with you during your first visit.
Acupuncture Treatment Consent
Review this document if you are receiving acupuncture. Your physician will review this with you during your first visit.
Lidocaine Treatment Consent
Review this document if you are receiving a lidocaine treatment. Your physician will review this with you during your first visit.
Some therapies may not be suitable if you are pregnant or breastfeeding.
If you want us to talk to anyone else about your medical care, fill out this form.
Pay for a Treatment
Convenient way to pay online for our most common service offerings.
2425 Grand Avenue #104
Glenwood Springs, CO 81601
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satori integrative medicine clinic • 2425 Grand Avenue #104 • Glenwood Springs, CO 81601
phone: 970-832-0800 • fax: 970-832-0808 • email@example.com