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Patient Details

First name*

Last name*

Date of Birth*

Month

Day

Year

Gender*

Male

Female

Other

Street Address*

City*

State*

Zip Code*

Home

Mobile*

Email*

Ethnicity/Race*

Weight*

Height*

Primary Language*

English

Spanish

Other

Marital Status*

Spouses Name

Phone

Emergency Contact

Emergency Name*

Relationship*

Home

Mobile

Email*

I have read and agree to the Client Waiver & Agreement Covers: Sections 1, 4, and 5 — services disclaimer, assumption of risk, data collection notice, minor consent

I have read and agree to the HIPAA Privacy Notice Covers: Section 2 — how health information is used, shared, and protected

I have read and agree to the Genetic Testing Consent Covers: Section 3 — testing purpose, benefits, risks, voluntary participation

(Optional) YES, you may use my/my child's de-identified data for future research

VISIT US

833 SW Adams St.
Peoria, IL 61602
Get directions

(309) 499-4657

Functional health & wellness, built around your biology. Peoria, IL.

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