• Child New Patient Intake Form

    Complete this before your appointment and your provider can be better prepared during their time with you.
  • Patient Information

    This information will be sent to your provider and will be kept as part of your patient records.
  •  - -
    Pick a Date
  • Current Health Condition

  • Past Medical History

  • Consent to Treat Minor

  •  

     I hereby authorize Genesis Integrative Medicine, LLC and any providers employed therein to administer treatment as deemed necessary to my child.

  • Clear
  •  - -
    Pick a Date
  • Release of Information

  •  This is confidential record of my medical history and pertinent personal information. The doctor/nurse practitioner reserves the right to discuss this information with medical and allied health professionals per this informed consent. Copies of this record can only be released by your written authorization. Copies of this record can only be released by your written authorization. 

  • Clear
  •  - -
    Pick a Date
  • Informed Consent for Treatment/Diagnostic Imaging

  • To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor's office of any changes in my medical status. I certify that I am the patient or legal guardian of the above listed patient. I authorize this office and its staff to examine and treat my condition as the medical professionals see fit, including having diagnostic x-ray examination if necessary. 

  • Clear
  •  - -
    Pick a Date
  • Insurance Information

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Should be Empty: