We would like to welcome you to our practice and ask that you kindly complete all information listed.

  • PATIENT INFORMATION

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  • EMERGENCY CONTACT

  • PRIMARY MEDICAL INSURANCE

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  • SECONDARY MEDICAL INSURANCE

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  • CURRENT HEALTH CONDITION

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  • MEDICAL HISTORY

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  • FAMILY HISTORY

  • Please list family history according to the format above
  • RELATIONSHIPAGEHEALTH PROBLEMS 
  • SOCIAL HISTORY

  • Please Note: Any Medical Emergencies - Please call 911 or Go to the Nearest Emergency Room

  • FINANCIAL DISCLOSURE


    At Delaware Integrative Medicine, we have partnered with a few insurance companies in an attempt to lessen the financial burden on our patients. The insurance companies we partner with, typically cover office visits, technical fees involving injection, IV and Ultrasound tests. Most insurance companies do not cover expenses related to the administration of therapies used here to treat you including: ozone; UBI; PEMF; FSM; IV therapies (Myers, MAH, Glutathione, Chelation); saunas, etc.

    You are responsible for any our-of-pocket expenses not covered by your insurance. If you do not have insurance, you are responsible for all fees including office visits and any additional fees.

    If you default on any payment due, your account will be turned over to our collection agency. You are responsible for any fees or court costs as a result of our collection efforts. Late fee, charge and interest can be 18-24% as allowed by law
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