Please fill out this form as thoroughly as possible. All information is completely confidential and will not be released unless you authorize us to do so.
Your signature below signifies that you have read and acknowledged the policies regarding:
I attest that the above information is correct to the best of my knowledge.
I also certify that I, and/or my dependent(s), have insurance coverage with the insurance(s) provided and assign all insurance benefits, if any, directly to the Diabetes Metabolic Wellness Center. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The clinicians assigned to the Diabetes Metabolic Wellness Center may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below:
FULL DISCLOSURE: Any protected health information this provider and its affiliates collect and maintain, including mental health, HIV, sexually transmitted diseases, health status, alcohol and substance abuse treatment records, and genetic testing. This also includes information on health treatment programs, plan information, and caregiver resources with the person being authorized.
LIMITED DISCLOSURE: Identify what protected health information is to be excluded from any disclosure. Such as a medical condition or treatment information or a specific date range of services.
I understand that:
Organization: Diabetes & Metabolic Wellness CenterAddress: 66 Gruene Park Drive Unit 210 City, State, Zip: New Braunfels, TX 78130 Phone: (830) 730-4375 Fax: (830) 730-4203
Welcome! We are so excited you’ve made the decision to improve your well-being and quality of life through nutrition therapy. We find it very helpful to learn a little bit about you prior to our first session. This helps us to better understand your needs, preferences, and goals in order to offer realistic and personalized care for your health concerns.
If you become overwhelmed, find any of the questions challenging, or don’t feel comfortable answering, please leave them blank. Only complete the sections which feel appropriate to you to complete.
Welcome to Diabetes & Metabolic Wellness Center! We are delighted you have chosen our practice to provide you with your health care.
We schedule our appointments so that each patient receives the right amount of time to be seen by our physicians and staff. That is why it is especially important that you keep your scheduled appointment with us and arrive on time.
As a courtesy, and to help patients remember their scheduled appointments, Diabetes & Metabolic Wellness Center sends text messages and phone call reminders.
If your schedule changes and you cannot keep your appointment, please contact us with at least a 24 hour notice so we may reschedule you, and accommodate those patients who are waiting for an appointment.
If you do not cancel or reschedule your appointment with at least 24-hour notice, we may assess a $50 “no-show” service charge to your account. This “no-show charge” is not reimbursable by your insurance company. You will be billed directly for it.
I understand that I must cancel or reschedule any appointment at least 24 hours in advance in order to avoid a potential no-show charge.