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.
Energy clinic opportunity
Nov 11-15, Ann Arbor, Michigan
New Workshop series
June 22, 2019 10am-6pm, 1st of 4 workshops in the series
contact email: email@example.com
Chapel Hill, NC
Lauren, email firstname.lastname@example.org
Cortes Island, BC
EAGLE SWEEP INTEGRATIVE INTERNAL MEDICINE
ENERGY CLINIC PATIENT REGISTRATION
Patient Name (legal):_________________________________________
Birthdate: ___ / ___ / __legal Sex: M / F
Preferred Name __________________________________________ Gender M F GQ Other
Home Phone: _______________________
City:_______________________ State: _____ Zip:___________
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
In case of emergency, relative or friend
Home Phone ______ ___________Work Phone: ________
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.
Patient Name:_________________________________________ Birthdate: ___ / ___ / ___
Patient/Guardian Signature _______________________________ Date ___________________________
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.
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.