Restorative Wellness Form

This document serves as a centralized and secure record for patient care. It is intended for use by authorized medical professionals and collaborators to ensure accurate, up-to-date communication and continuity of care. All information contained within is confidential and protected under HIPAA and other applicable privacy laws.

Please ensure all entries are dated, clearly labeled, and professional written. For questions or updates, contact Rosie Wandell at 561-317-1040.

First name

Last name

Email

Address

Date of Birth

Month

Day

Year

Phone

Primary Care Provider (PCP) Name

PCP Email

Permission to contact PCP

Yes

No

Please list all current medications

Please indicate any surgical procedures

Do you have any current injuries or health conditions to be aware of? Please indicate below and if the answer is "yes", please explain.

Please indicate any allergies to be aware of including latex or food allergies (If none, please indicate N/A)

Are you currently pregnant or nursing? (Females only)

Yes

No

Are you currently under medical supervision or medical care?

Yes

No

By completing and submitting this form, I acknowledge that I have read, understand, and agree to the 24-hour cancellation policy. I understand that if I do not provide at least 24 hours' notice to cancel or reschedule my appointment, I will be responsible for the full session rate as outlined at the time of scheduling. This policy is in place to honor the time and preparation of the provider and to allow others the opportunity to book the available time slot.

I acknowledge

Yes

No