First Visit Forms

Spicer Wellness Center New Patient Forms

I am eager to serve your health care needs. I respect your time and would like to make your visit to the office as efficient as possible recognizing that sometimes things get a little hectic and that your appointment time might be altered slightly due to a special need of a patient scheduled before your visit.

I would appreciate it if you would download the forms to your desktop, print them, and complete the medical information sheet/s and bring them with you to your appointment. If you are transferring your care to Spicer Wellness Center from another facility, please call the former health-care provider and ask to have your records transferred to Spicer Wellness Center.

Please bring your insurance card with you so we can file your insurance claim. Your insurance reimbursement may not cover the full cost of your exams or your physician services. I am contracted with many insurance providers, however, if you're uncertain of your covered services, please contact your insurance carrier. Regardless of insurance, payment remains your personal responsibility.

Plan to arrive 10 minutes prior to your appointment and notify the office as soon as possible if you are unable to keep your appointment. I look forward to serving you!

Yours in Health,

Dr. Tom.

Adult new patient forms

Please download and complete all areas of the Adult new patient form and bring it in with you.

Child's new patient form

Please download and fill out and bring this Child's new patient form in with you for your first appointment.

Motor Vehicle Accident Forms

Please fill out as much information as you can on the attached Motor Vehicle Forms.

Download Combined_MVA_1st_visit_forms_for_web.pdf

Nutritional Questionaire

Good nutrition is closely linked to the toxicities in our lives and how our body either removes toxins from our bodies or hides them in fat. Please download all 3 forms (Toxicity and Nutritional and 7 Day Food Profile) complete them, and bring them in to your free nutritional consultation. If we agree that nutrition could be an additional improvement in the quality of your life, we will schedule a nutritional exam appointment at a later date. Click on this link to download your Nutritional Questionnaire.

Download Standard_Process_Nutrition_questionaire_pdf.pdf

Toxicity questionaire

Toxins are in our environment everywhere. From the deodorants and soaps we use, to the diesel and gas fuels we breathe in, to the products under our sinks, we are exposed to thousands of chemicals that are new to our bodies’ defense mechanisms. If our bodies work at optimum efficiency and we eliminate these toxins, we stay healthy. If not, disease eventually results. Check your exposure and ability to remove toxins from your body by filling out the Toxicity Questionnaire and bring it into the office for a consultation.

7 Day food profile

Here's a 7 Day Food Profile to truly track what you put in our mouth for the next 7 days. No cheating! Eat what you normally do and write it down. Bring in the form to your nutritional consultation.

Download Daily record of food intake.pdf

Acupunture forms

Please fill out this Acupuncture form before your 1st visit.

Download 5 phase acupuncture intake form.pdf