Travel clinics

By request, Dr Taylor has started providing energy healing sessions and workshops elsewhere. If you wish to see him in one of these sites which may be closer to you, approximate dates of clinics and organizer’s contact info are below. There is also a registration sheet you can print and bring with you. The organizer will have details for questions you will have at that site.

2019

Energy clinic opportunity
Nov 11-15, Ann Arbor, Michigan
contact: drtaylor@eaglesweepclinic.com

New Workshop series
Bremerton, WA
June 22, 2019 10am-6pm, 1st of 4 workshops in the series
contact email: drtaylor@eaglesweepclinic.com

2017/2018

completed workshops
Chapel Hill, NC
Lauren, email laurenjube@gmail.com

Cortes Island, BC
Fawn, fawnbaron@gmail.com

EAGLE SWEEP INTEGRATIVE INTERNAL MEDICINE

ENERGY CLINIC PATIENT REGISTRATION

 

Patient Name (legal):_________________________________________

Birthdate: ___ / ___ / __legal Sex:   M  /  F

Preferred Name __________________________________________         Gender    M      F    GQ     Other

Address:_____________________________________________

Home Phone: _______________________

City:_______________________ State: _____ Zip:___________

Cell Phone/Other:____________________

Email_____________________________________________________________

yes/no    use my email for appointment notifications and clinic related issues

yes/no  use my cell phone number for appointment notifications and clinic related issues

Marital Status: _____________

spouse’s name if  assisting you__________________________

If patient is a minor, responsible person with who minor resides

____________________________________________________

(Name)             (Relationship)

Cell/Mobile Phone______________________________

In case of emergency, relative or friend

Name__ _______________________________

Home Phone ______ ___________Work Phone:       ________

 

Cell:____________________Relationship_________________________________

Disclosure and Release

I authorize treatment of the person named above and understand that I am responsible for payment of this service regardless of insurance coverage or third party agent.  I understand and accept that Dr Taylor does not accept insurance payments and I am responsible for the payment of services rendered on the date of service, all fees are due at your visit.

Signature: ___________________________________________________

Date: _____________________

Patient Name:_________________________________________      Birthdate: ___ / ___ / ___

Patient/Guardian Signature _______________________________     Date ___________________________

CANCELLATION POLICY

 I understand that an appointment time has been reserved especially for me. Prepaid fees are non-refundable unless Dr. Taylor must cancel, then all fees are refundable or may be applied to a new appointment.

Signature_____________________________________________  Date_________________________

 

HIPAA

 NOTICE OF PRIVACY PRACTICES-ACKNOWLEDGEMENT

We are not keeping a record of this alternative medicine treatment. We will not disclose your information to others unless you direct us to do so or unless the law authorizes us or compels us to do so.

 Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access your information.

By my signature below I acknowledge receipt of the Notice of Privacy Practices.

________________________________   ____________________________

Patient or legally authorized individual signature                                         Date

Short description of health issues to be addressed by treatment. If you have a medical diagnosis, please list as this is helpful for Dr Taylor to understand the process.  Also, please list other treatments you have undergone, dates, and outcomes of these treatments, ie helped and how, or did not help.

 HIL