Providers, to refer a new patient, please fax us this Refer a Patient Form.
Please print and bring completed “required” forms with you to your 1st appointment.
Print and Complete the following to bring to your 1st appointment.
Self-Pay Agreement (required for those not using insurance)
Assumption Of Risk (required to leave office for walk, meal or experientials)
Credit Card/HSA Card Authorization (required for copays and balance)
Copays are due at the time of your appointment. We accept cash, check, Visa or MasterCard.
We Accept The Following Insurance. Please confirm your medical plan coverage with your insurance provider; “In-network status does not guarantee plan coverage for nutritional therapy.”
Phone: 888-PHR-4ALL (888-747-4255)