♟Health and Wellness | New Patient Registration

Health and Wellness♟ New Patients

Let's get to know you...in private.
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Submission Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Patient Gender (at birth)*
Patient E-Mail*
example@example.com
Phone Number*

Area CodePhone Number
Preferred Method of Contact

EmailTextGood Old Fashioned Phone Call
Address: Please list the location you would like a service at. *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Appointment
I'm here for Peptide Therapy:*

Yes, I am here to start peptides.No, I am here for something else.
Are you currently on any peptides?

Yes, I am currently taking peptidesI have used peptides the past, but I am not currently taking any peptidesNo, I have never used peptidesI am not here for peptides.
If you answered Yes, please list the type of peptides you are on and the duration of use:
Peptide Therapy Clients Only: Have you ever experienced any unwanted side effects from peptide therapy or other treatments?

Yes, I had major undesirable effects from peptide therapyNo, I did not experience side effectsI had mild side effects (ie: nausea/discomfort at injection site, headaches)
If you answered Yes, please describe the side effects experienced:
Peptide Therapy Clients Only : Please select all options that apply to what you need for your peptide regimen:

Initial Lab WorkPeptide Telemedicine ConsultationPeptide Therapy Administration/TeachingPeptide Refill or Dosing Re-evaluation
Peptide Therapy Clients Only: What are the main reasons you are considering peptide therapy? Please select all that apply:

Weight LossMuscle GainAnti-AgingImproved SleepImproved LibidoEnhanced Cognitive FunctionI am unsure
Peptide Therapy Clients Only: Do you experience any of the following symptoms?

FatigueInsomniaMood SwingsMemory IssuesJoint PainMuscle WeaknessOther (Please Specify below)
Other:
If you answered that you are here for something else, please check all that apply. I am interested in the following treatments:*

MassageYogaReikiSound HealingLife CoachNutritionDiet/Weight Loss ManagementExercise/FitnessOther (not listed here)I am not looking for any other Health and Wellness treatments at this time.
Please upload any orders, forms, or referrals from your medical practitioner (if applicable):

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Why cover the whole bill if you don't have to? Upload the front and back of your insurance card here and we can see what we can get comped for you :)

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We want to put a face to your name. Please upload the front and back of your government-issued ID here:

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Medical History

We care about you...
Have you ever had (Please check all that apply)

AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysema
Other illnesses:
Do you have any allergies?*

YesNo
Please list your allergies:
Are you taking any medications?*

YesNo
Please list your Current Medications:
Please list Surgical Procedures & Dates of Each:
Healthy & Unhealthy Habits

No judgements, offering improvements upon request...
Exercise

Never1-2 days3-4 days5+ days
Eating habits/following a diet

I have a loose dietI have a strict dietI eat generally healthy, but I could make improvementsI don't have a diet plan
Alcohol Consumption

I don't drinkI am a social drinker (less than 5 drinks/week)1-2 glasses/day3-4 glasses/day5+ glasses/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
Do you Vape?

YesNo
Are there any other elements or substances in your routine?

CaffeineMarijuanaMagic MushroomsCocaineMDMA and/or 2CBLSDMethamphetamineOther
I give full permission to Checkmate Health Strategies to source my licensed medical provider for the therapy in which I am seeking. I understand that the medical personnel may not be employees of Checkmate Health Strategies, and are rather 3rd party contractors and/or affiliates. I authorize and consent to the therapies being administered by the EMT, RN, NP, PA, CRNA, DO, MD, or certified licensed practitioner that is affiliated with Checkmate Health Strategies. I have requested this service and/or therapy/health management. I have been counseled on all risks, benefits, and possible adverse effects of the treatments.

I acknowledge that I have had the opportunity to ask questions and with respect to my proposed therapy and treatments to be utilized and all my questions have been answered to my full satisfaction.

My signature on this agreement will constitute a full and final release of any legal responsibility resulting from the administration of intravenous therapy in my case and/or any other medical treatments that may be necessary as a result thereof.
CHECKMATE HEALTH STRATEGIES AUTHORIZATION TO GIVE MEDICAL CARE – CONSENT TO TREATMENT: I hereby voluntarily consent to treatment and care from all medical personnel contracted with Checkmate Health Strategies. I further consent to the performance of any diagnostic procedures, examinations, laboratory tests and rendering of medical treatment by Checkmate Health Strategies’ medical Providers and staff, as is necessary in the medical staff’s judgment. I understand that this consent will be valid and remain in effect as long as I am a patient at the clinic. *

Clear
Booking Deposit Payment
prevnext( X )
Deposit (Health and Wellness)Non-Refundable. Pay remainder at time of booking.
$75.00

Total

$0.00
Should be Empty:

Health and Wellness♟ New Patients

Medical History

Healthy & Unhealthy Habits