Patient Forms & Insurance

The Center for Integrative Medicine accepts payment by cash, credit card or check. Payment is due at the time service. We are happy to provide receipts for our services for our clients to pursue insurance reimbursement.

Some physician services may be eligible for reimbursement as an “out of network” expense. It is the patient’s responsibility to understand their insurance coverage and submit paperwork as may be appropriate.

General Forms

Introductory Policy Letter (PDF)

New Patient Form (PDF)

Medical Release Form (PDF)

Notice of Privacy Policies (PDF)

Cancellation Policy (PDF)

Medicare Opt Out Form (PDF)

Acupuncture Forms

Acupuncture Patient's Form (PDF)

Cancellation Policy (PDF)

Chiropractic Treatment Forms

Informed Consent to Chiropractic Treatment Form (PDF)

Medical Release Form (PDF)

New Patient Form (PDF)

Privacy Statement Acknowledgement Form (PDF)

Cancellation Policy (PDF)

Cancellation Policy (PDF)

Chiropractic Pain Map (PDF)

Massage Therapy Forms

New Patient & Consent Form (PDF)

Cancellation Policy (PDF)

Notice of Privacy Policies (PDF)

Naturopathy Forms

Informed Consent to Naturopathic Care Form (PDF)

New Patient Form (PDF)

Release of Information, Assignment Benefits and Patient Privacy Form (PDF)

Cancellation Policy (PDF)

Notice of Privacy Policies (PDF)

Nutrition Forms

Patient History (PDF)

New Patient Form (PDF)

Medication Form (PDF)

Personal Health Assessment Form (PDF)

Daily Food Journal (PDF)

Medical Release Form (PDF)

Cancellation Policy (PDF)

Notice of Privacy Policy (PDF)

Pre- and Post-Natal Massage Forms

Pre- and Post-Natal Consent Form (PDF)

Pre- and Post-Natal Massage Client Info Form (PDF)

Notice of Privacy Policies (PDF)

Cancellation Policy (PDF)

Psychology Forms

Patient Forms and Policy (PDF)

Child Policy and Consent (PDF)