rejuvenationsfl.com-A-New-Patient-Paperwork

Rejuvenations Total Health Center
1575 Pine Ridge Rd. Suite #6 Naples, FL 34109
(239) 331-5886
RejuvenationsFL.com

Dear Client,

Welcome! ... And thank you for choosing Dr. Repice's TeleHealth Coaching.

HOW THE PROCESS WORKS:

STEP 1: During your initial Interview, Dr. Repice will review your health history and make recommendations for lab tests that are appropriate for your specific health issues.

STEP 2: Once you have completed your lab tests, Dr. Repice will explain the meaning of your test results to you in a follow up consultation. He will create an individualized therapeutic program for you including diet changes, nutritional supplements, and exercise, lifestyle and stress management advice.

STEP 3: Subsequent consults are scheduled to monitor your progress. Dr. Repice will also design an on-going wellness program to be reviewed and updated with our staff at no charge every six months.

We invite you to contact us via text, email should you have any questions during the course of your treatment. We may also be reached at (239) 331-5886 Hours are by appointment only.

We look forward to assisting you in achieving your current wellness goals, and to guiding you in maintaining wellness throughout your life.

In health,

Dr. Repice and Staff

New Client Paperwork

I clearly understand and agree that all services rendered to me are charged directly to me and that I am responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable. I authorize Dr Repice & Rejuvenations, Incorporated to release my personal medical information to me.
Clients Signature

Clear
Date

Month Day Year
Name

First Name Last Name
Date

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone

Area Code Phone Number
Cell

Area Code Phone Number
Work

Area Code Phone Number
Email
example@example.com
Emergency Contact
Please mark your preference for occasional follow up communication from our office:

Email Phone
Age
Date of Birth

Month Day Year
Date
Sex

M F
Marital Status

M S W D
No. Children
Occupation
Employer
Years Employed
Spouse’s Name
Occupation
Employer
Person responsible for this account
Referred by
What is your major complaint?
Other complaints?
What are your overall health goals once your complaints are resolved?
How long has it been since you really felt good?

POLICIES AND PROCEDURES

(please retain pg. 6 for your records)

New Clients
First Appointment

Your first Client Interview will be 45 minutes – 1 hour ($300). During this time Dr. Repice will
determine the appropriate lab tests you should order to address your specific health concerns.

Fee Schedule
New Client Coaching Program: ($300) (45 minutes - 1 hour)
1 hour: ($300)
30 minutes: ($150)
15 minutes: ($75)
- I Payment is due at time of the Coaching Call
- I Methods of payment are: All Major Credit Cards
- All Coaching Calls are timed from the time the appointment begins;
  you will only be billed for the actual time used.
Appointments
- I Follow-up Coaching may be scheduled in 15, 30, or 60-minute blocks of time.
- I We encourage you to book your appointments 2 weeks in advance.
- I As a courtesy to you, our office will message you to confirm your appointment in advance.
  You may also receive a reminder via email.
Lab Tests
- I The results of your lab test(s) will be sent to Dr. Repice 2 to 4 weeks after mailing your specimens to the lab.
- I Dr. Repice will evaluate the results. After evaluation you will be contacted to schedule a follow-up appointment.
Cancellations
- I If you are unable to keep your scheduled appointment, you must notify our office a minimum of 48 hours before your scheduled time or you may be charged for that appointment.
Returned Products
- I PRE-APPROVAL is REQUIRED on ALL RETURNS!!
- I Prepaid lab tests can be returned for credit within 30 days of purchase.
Important Notes
- I Dr. Repice is not a medical doctor; he does not service medical emergencies.
  If you have a medical emergency, you must contact your primary care physician or dial 911!
- I Please contact the office if you are not clear on any of our policies or procedures.
I
have read and understood Dr. Repice and Rejuvenations, Inc Policies and Procedures.
Signature

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Date

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Date