APPOINTMENT REQUEST FORM & FEE SCHEDULE
 
*** IMPORTANT ! PLEASE FOLLOW INSTRUCTIONS ***
WE CANNOT FACILITATE APPOINTMENTS WITH OUT A SIGNED APPOINTMENT REQUEST FORM,
HEALTH INTAKE FORM, CONSENT FORM
 
CONSENT FORM / HEALTHINTAKEFORM / APPOINTMENTS & SERVICE OPTIONS

INSTRUCTIONS: PLEASE FILL OUT ALL PERTINENT INFORMATION BELOW ON-LINE (BE SURE TO USE ALL CAPITALS SO WE CAN READ IT). PRINT OUT THE FINISHED FORM, SIGN AND SEND BY FAX OR MAIL. OR IF PREFERRED, SAVE IT AS A .PDF DOCUMENT TO YOUR DESKTOP AND EMAIL IT TO US. NOTE: USING A 75-80% ON YOUR PRINTER PAGE SET UP WHEN PRINTING WILL HELP LIMIT THE NUMBER OF PAGES IT PRINTS ON AND INSURE WE GET EVERYTHING.
PERSONAL INFORMATION
 Name:
  Today's Date:
Blood Type : O+; O-, A+, A-, B+, B-, AB+, AB-
 Telephone:
  Cell #:
 FAX:
Height:
Weight:
Staatus: M S W D DP
 Address:
  City:
State: Zip:
 E-Mail:
  Confirm E-Mail :
Occupation:

 Financially Responsible Party:
 
 Telephone:
 Address:
 City:
 State: Zip:

 BEST TIMES TO REACH YOU BY TELEPHONE:
 SCHEDULING CONSIDERATIONS:

 APPOINTMENT OPTIONS (Please Select Appointment Type You Are Requesting By Clicking On The Dot )
 
APPOINTMENTS & SERVICE OPTIONS
SELECT ( X )
 NEW APPOINTMENTS
  FEE

 

 

 
QUANTUM COMPREHENSIVE IN PERSON VISIT IN LAKE ARROWHEAD :
Time: 1-3 Days. Both Dr.B. & Dr.McC. work together. We come to your hotel room and work for privacy and real time monitoring. Day 1 includes up to 10 hrs. of DNA Field Analysis, Physical Exam, Chiropractic, Physiotherapy, Consult, etc. (i.e. Day 1=$1500 + Day 2: 5 hrs. x $150=$750, Total $2250) ÝÝ
 
 
$1500.00 Day 1 (up to10 hrs.) +
$150/ hr thereafter ***
  BASIC Includes an In-depth Case & Records Review, Intake, Consultation, Strategy. Can be done via Phone or Skype® or in-person at a local hotel lobby or restaurant in Lake Arrowhead or Crestline.  
$285.00 / 1-2 hrs.**
  ADVANCED Includes everything in the Basic consult but also includes limited DNA Field Analysis to get more in depth information.  
$385.00 / 2-3+ hrs.**
  FIELD VISIT-Within 90 Mile Radius We meet at a local restuarant, hotel lobby, etc. I only do House Calls under rare circumstances (i.e. bedridden, etc.) Based on availability. Includes an In-depth Records& Case Review, Intake, Consultation, Strategy, etc. No DNA Field Analysis included but can be added on for a small fee if that's of interest.  
$475.00 / 3+ hrs. **
 
EUROPA MEDICAL CLINIC NEW PATIENT INITIAL CONSULT (Clinic is in Tijuana, Mex.) Includes Preliminary Case & Records Review, History, Consultation, etc. Then we schedules a clinic evaluation with our physician which includes a full physical exam, lab work, live blood cell analysis, consultation, etc. Allow Approx. 4-5 hrs. at the clinic. Clinic Eval. Fee is applied to treatment fees for the first week should the patient choose to stay and start treatment. Clinic Fee is paid directly to Dr.Sonia at the time of service, approximately $400.00.
 

$295.00/ 2 hrs.*

Note: This does NOT include the clinic New Patient evaluation fee.

 
 EXISTING CLIENT FEES
    FEE
Existing Patient Fee (Office, Phone, Skype®)
$75.00 / 30 min.
Existing Patient Quantum Energy Evaluation & Resolution w/ both Dr.B.& Dr.Mc
 
$150.00 / hr. (1 hr. min)
 
MISCELLANEOUS 
   FEE
DNA FIELD ANALYSIS / MICROKINESIOLOGY SESSION
Can be done virtually via phone or Skype®, or in person.
 
$65.00 / 15 min.
 

TOTAL

   $
 

3% CC Facilitation FEE

 
 $
   TOTAL DUE:  
 $
 

LESS DEPOSIT PAID *** 

   $
 

TOTAL DUE: 

 
 $
 
FINANCIAL POLICIES:
** Overtime billed at $75 per 30 min.
*** A $150 Non-refundable Deposit is required for Advance Appointments more than 2 weeks in advance to block time. It is applied to total due unless the appointment is cancelled.
** A 150 Cancellation Fee applies for Non-Advanced Appointments (less than 2 weeks in advance) cancelled within 72 hrs. of the appointment
Note: Appointments which are booked for less than 2 weeks in advance require 100% Prepayment. Cancellation Fee Applies.
Credit Charge charges are assessed a 3% facilitation fee for Domestic and 4% for Foreign cards
ÝÝ Examples Only. Actual fees vary since we don't know what Day 2 time will be.
 

PAYMENT INFORMATION: PLEASE SELECT ONE -- "X" & PLEASE TYPE IN ALL CAPS
Patient Name Telephone Date
PLEASE SELECT PAYMENT METHOD BELOW
VISA MASTERCARD DISCOVER POSTAL MONEY ORDER BANK DRAFT WIRE CASH
FOR QUESTIONS ABOUT PAYMENT & FINANCIAL POLICIES, SEE  Financial Policies & Terms
Credit Card# Expiration Date
3-Digit Security ID# on reverse to the far right of signature
Card Holders Name As it Appears on Card : PLEASE USE ALL CAPS
Card Billing Address:City: State Zip Code Phone
Authorization Virtual Signature: (Please Type Name as it appears on the card in ALL CAPS--virtual signature )
 
Hard Signature _______________________________________________
 
By typing your name and information here, you are stating you understand and agree to our terms and policies and are the authorizing cardholder and authorize Arrowhead HealthWorks™ to charge the above credit card for the services or items selected above. If you are not the authorized cardholder, we need a written permission slip accompanying the order before we can bill the card.

THIS FORM MUST ACCOMPANY THE HEALTH INTAKE FORM AND SIGNED CONSENT FORM.
ALL PERTINENT MEDICAL RECORDS SHOULD ALSO BE SENT TOGETHER WITH THESE FORMS.
 HealthIntakeForm
 Consent Form

TERMS AGREEMENT HARD SIGNATURE REQUIRED:
*** I have read and understand all of the terms and policies set forth in the attached forms and agree to comply with them.
  (typed name in CAPS )
 
________________________________________________________ (hard signature)
( Patient or financially responsible party signature )
(typed date)
 
_____/_____/______ (hand written date)

IMPORTANT -- GETTING THIS INFORMATION TO US
1. FAX -- Because Internet pages vary a lot, Please Print this form at 80% or Use Shrink to Fit in Printer Option Window Prior to printing to Insure we get everything. Without this, many times we loose info because it runs off page margins. Thanks !
 
2. E-MAIL-- You can fill each of our forms out online and then save it as a PDF File and drag it to your email window and send it to us that way. To make a PDF file, Go to "PRINT" and select "Save as PDF" Option from your Printer Window. Save it to the desktop. Open your Email program and after addressing it, attach the PDF off your desktop to the Emai. When we get it, we'll open it and print it off here. PDF files are typically encrypted and so the information is actually safer than faxing would be.
 
3. US MAIL-- If you're unsure what to do or uncomfortable with these options, call us. We can send PDF files of each of the forms via email directly so you can print them, fill them out by hand and mail them to our PO Box below.

©1994-2019 Arrowhead HealthWorks ™ P.O.Box 3668, Crestline, CA 92325
(909) 338-3533 / FAX (909) 338-3743
E-mail: cbormann@dslextreme.com *ARROWHEADHEALTHWORKS.COM