Fresh Start Wellness Appointment

Pre-Appointment Intake Form

Please complete our intake form before your appointment. You may complete and submit the form below, or download and print a PDF version.

  • Patient Information

  • Date Format: MM slash DD slash YYYY
  • How Did You Hear About Our Office

  • Personal Health History

  • Date Format: MM slash DD slash YYYY
  • (name, amount, frequency, length of use, reason for use)
  • (name, amounts, frequency, length of use, reason for use)
  • Personal Incident History:

  • Social History & Life Choices:

  • Health Problems & Concerns:

    Check All That Apply
    Check All That Apply
  • Health Goals:

  • Terms & Agreement

    *Fresh Start Wellness, LLC, products, programs, website, and services are not intended to replace medical treatment of any kind. We recommend consulting your doctor prior to making any changes to your diet, exercise, lifestyle, medications and/or supplementation. By accepting services you acknowledge, understand and agree that your are doing so on your own initiative and at your own risk and that in doing so, your health decisions are your responsibility and not the responsibility of Fresh Start Wellness, LLC. While the information conveyed in our programs and services and on our website were prepared to provide accurate information regarding topics related to general and specific health and wellness, the information is made available with the express understanding that Fresh Start Wellness, LLC is not dispensing medical advice and do not intend any of their information to be used for diagnosis or treatment. If you have any questions or concerns about your health and before starting or stopping any treatment or acting upon information related to any of our products and services, you should contact your own physician or health care provider.