Chelation Maine accepting new patients


 

Patient Forms

HEALTH QUESTIONAIRE:
For our new patients, please print out the following form, and fill out before your initial office visit:
New Patient Health Questionnaire

AGREEMENT FOR MEDICAL PHONE CONSULTATION:
This form must be filled out and on file in our office prior to phone consultations with Doctor Psonak.
Agreement for Medical Phone Consultation

OBTAINING MEDICAL RECORDS FROM YOUR PROVIDER:
To make your visit with the doctor more efficient, it is recommended that a copy of your previous medical records be available at the time of your visit.  If you need to obtain a copy of these records you should either contact your health provider directly, or the following form may be used to send to your health provider:
Request for medical records to be sent to us from your health care provider

LIFE EXTENSION RELEASE FORM:
If you have had a Blood Profile you wish to discuss with Dr. Psonak, please fill this form out and return it to the office.
Request to release your lab results to Life Extension for consulting purposes

REQUESTING YOUR MEDICAL RECORDS FROM US:
If you need a copy of your medical records which are in our office, you may use the following request form:
Request to release your medical records to a another health practitioner

PARENTAL CONSENT:
If the patient is a minor under the age of 18, and the parent/guardian is not present, the following form is required:
Parental consent form for a minor under the age of 18













Specialized form - To be used only when specifically instructed by the office


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