Functional Medicine Intake Form

Welcome to our office!

Thank you for choosing us for your functional medicine care. Please complete this intake form as thoroughly and accurately as possible. If you have any questions, feel free to call. We're committed to providing the highest quality care to support your health and well-being.

About this Patient

Reason for this Visit

What Musculoskeletal issues reported?*
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What neurological are issues reported?*
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What Head and ENT issues are reported?*
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What cardiovascular issues are reported?*
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What respiratory issues are reported?*
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What gastrointestinal issues are reported?*
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What genitourinary issues are reported?*
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What endocrine issues are reported?*
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What dermatological or hemopoietic issues are reported?*
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What allergy or sensitivity issues are reported?*
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Name past illnesses:*
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Patient's Immediate Family Health History?*
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Social habits?*
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Exercise routine?*
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Diet and nutrition?*
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Is complaint getting better, worse or staying the same?*
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Has patient received any past care for this complaint?*
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Have any recent diagnostic images or tests been performed?*
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Sunset Hills Chiropractic

4600 S. Lindbergh Blvd. Suite 3, St. Louis, MO

63127 Office: 314-729-0027 / Fax: 314-729-1045

HIPAA & Authorization to Release


I understand and agree to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operation, and coordination of care. I understand that should I need a more detailed account of my policy and procedures concerning the privacy of my Patient Health Information, I am welcome to read the HIPAA Notice that is available at the front desk before signing this consent. No notice of a missed or late appointment within the 2 hours will result in a $100 cancelation fee. 

In Order for our office to provide ANY information to your Spouse, parent, relative or other designates, we must have your permission. (This would include appointment schedules, X-Rays, receipts, Insurance Information, health records and any other information that pertains to your treatment.) You may indicate your permission by listing names below.

Please indicate the name and contact information of your primary care physician for the purpose of care coordination.

The undersigned does hereby consent to the use of his or her health information in a manner consistent with the Notice of Privacy Practices Pursuant to HIPAA Compliance Manual, State Law and Federal Law.

Patient Signature
If patient is a minor or under a guardianship order as defined by State law select which on applies to you
Parent/Guardian Signature

Informed Consent to Functional Medicine

Functional Medicine Informed Consent

I hereby request and consent to receive functional medicine services, including but not limited to consultations, lifestyle and nutritional recommendations, supplement protocols, lab testing, and other assessments or therapies deemed appropriate by the provider, for myself (or for the patient named below, for whom I am legally responsible. from Dr. Darren Kirchner and/or Dr. Kelly Kirchner at Sunset Hills Family Chiropractic.

I understand that functional medicine services focus on identifying and addressing the root causes of health concerns through a patient-centered, integrative approach. These services may include personalized nutrition and lifestyle guidance, supplementation, diagnostic testing (including lab work), and holistic wellness strategies.

I understand that functional medicine is not a substitute for primary or emergency medical care, and that Dr. Darren Kirchner and Dr. Kelly Kirchner are not acting as my primary care physicians. I understand that these services are considered wellness services and are not billed to insurance.

I have had the opportunity to discuss the nature and purpose of functional medicine services, including any proposed tests or recommendations. I understand that results may vary and are not guaranteed.

As with any health intervention, I understand that there may be risks associated with nutritional supplements, detoxification processes, or other recommended interventions, including but not limited to allergic reactions, digestive discomfort, fatigue, or interactions with other medications or treatments. I agree to inform my provider of all medications, supplements, and medical conditions to minimize potential risks.

I have read, or have had read to me, the above consent. I have also had the opportunity to ask questions about its contents, and by signing below, I agree to receive functional medicine services as recommended by my provider. I intend this consent to apply throughout the course of my care for current and future concerns addressed through functional medicine at this facility.


 

To be completed by the patient:

Patient Signature

To be completed by the patient's representative, if necessary, (eg: if the patient is a minor or is physically or mentally incapacitated)

Sunset Hills Family Chiropractic

Dr. Brittany Warren • Dr. Robyn Kuhn • Dr. Nathan Free • Dr. Kelley Kerchner

Dr. Michelle Blaskow • Dr. Victoria Hopler, Dr. Darren Kerchner

4600 S. Lindbergh Blvd, Suite 3 St. Louis, MO 63127

P: 314-729-0027 F: 314-729-1015

 

Payment Policy

We require all patients to store a credit card on file. Your card will not be charged until after we submit your claims to your health plans. You will only be responsible for any amount that your health plan indicates that you owe. We will not charge your card if you do not owe anything. A 3% processing fee will be applied to all credit card payments.  

Privacy Note:

When your credit card information is entered, it is encrypted and cannot be viewed or accessed by our organization. Your system is registered with Visa and Mastercard and independently certified as a PCI-DSS Level One Service Provider. 

Authorization:

Until further notice, I authorize SUNSET HILLS FAMILY CHIROPRACTIC to charge the patient responsible balance on my account to the following credit card.

Choose One

I understand that all functional medicine services provided at SUNSET HILLS FAMILY CHIROPRACTIC are considered wellness services and are not billable to insurance. I agree to pay in full for these services at the time they are rendered. SUNSET HILLS FAMILY CHIROPRACTIC does not submit insurance claims for functional medicine services.

I acknowledge that any additional lab work related to functional medicine care will be charged and must be paid in full before the labs are performed. Payment is required prior to the collection or submission of any lab work.

I authorize SUNSET HILLS FAMILY CHIROPRACTIC to charge my credit card on file for any functional medicine services provided, including any outstanding balances. I request to be notified in advance before any charges are made to my card.

I further understand that if, after making a payment by credit card, I later dispute the charge, I agree not to cancel, revoke, charge back, or dispute any authorized charges unless prohibited by law. If a chargeback or dispute is initiated and it is determined that the charge was properly authorized, I agree to reimburse SUNSET HILLS FAMILY CHIROPRACTIC for any associated fees or costs incurred.

This authorization will remain in effect until I provide written notice of cancellation.

Please notify me in advance if charging my card by:*
Please select at least one option

If you have had any blood work done within the last year, please bring it with you to your appointment. Thank you!

Thank you for taking the time to fill out this form.

Locations

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Office Hours

Monday  

8:00 am

6:00 pm

Tuesday  

8:00 am

6:00 pm

Wednesday  

8:00 am

6:00 pm

Thursday  

8:00 am

6:00 pm

Friday  

8:00 am

5:00 pm

Saturday  

8:00 am

12:00 pm

Sunday  

Closed