CONTACT IN CASE OF EMERGENCY:

HEALTH CONCERNS

Please List your other health proffesionals (not to be contacted without your concent)

• I understand and agree that YOUTHPLUS MEDICAL CLINIC do not provide Primary Care Management. They provide health optimization
  through personalized nutritional solution.
  I understand that payment is due in full at the time of service.
• I understand hat I will be billed for any confirmed appointment missed or changed with less than twenty-four hours notice.
• I understand that no claims or guarantees have been made by YOUTHPLUS MEDICAL CLINIC personnel for future insurance
  reimbursement or particular medical outcomes.
• I understand that all information given to YOUTHPLUS MEDICAL CLINIC now or at any point in the future is entirely confidential. It is
  YOUTHPLUS policy to follow HIPPA guidelines IH requires a signed medical release form before releasing medical records to anyone other
  than myself unless legally required to do so. I may choose to keep a release form on file to expedite the handling of my records.
  
• My signature below gives YOUTHPLUS MEDICAL CLINIC CORP. my permission to email medical records to myself at an email address
  given to YOUTHPLUS by myself without a signed consent.
  At times, email or fax maybe the best option to communicate confidential medical information between myself and my doctor.
  
• I understand these are not secure forms of communications and my records will not be protected when using these forms of
  communication.

FOR THE PARENT OR GUARDIAN

TOXIC EXPOSURES

CONTEXT OF CARE REVIEW

PERSONAL AND FAMILY HEALTH HISTORY

Please check the box if it applies. Indicate details if any.

Check all that apply.