Dr. Deborah Bernstein - Holistic Healing Center
 

FORMS

Thank you for choosing the Holistic Healing Center.  Our scheduling policies have been developed to reduce wait times for initial appointments.  We therefore require that your forms be completed and submitted prior to being scheduled. 

In order to be scheduled for an appointment, you must first complete and submit the forms.

There are now 2 options available for completing the forms.  Our newest option allows you to complete the forms online. This method is to simplify and reduce the time you will need to spend on filling out the forms.  With this option, each individual form has to be completed in one sitting before you hit the submit button. Once you complete the form and hit submit, we receive notice that your form has arrived. It’s that easy! This method works using all devices as well as your standard computer.

Option 1  Fill Out and Submit Online

The following links, numbered 1- 8, will each take you to our online site for completing and submitting the form electronically. 

In general, most of the forms take around 5 minutes or less, but the Adult Medical Questionnaire takes approximately 15-20 minutes, so leave yourself time to do that form in one sitting.

1. Patient Consent and Office Policies 

2. Patient Information Form 

3. Medical Symptoms Questionnaire  

4. Symptoms Checklist Part 2

5. Adult Medical Questionnaire

6. Family History

7. For Women Only

   

8. Diet Assessment Questionnaire 

Option 2 Downloadable Fill in PDF forms  (This option is for those who either want to finish forms a little at a time or would like to handwrite the forms and drop them off or send in via email or USPS)

All the forms below are downloadable fill in PDF forms except for the Patient Consent Form and Office Policies. The forms will take approximately 45 minutes to complete; once we receive your completed forms, we will contact you to schedule your appointment.

Very Important! To avoid emailing blank forms, after filling out the forms below on your computer, do not click the top right download button as it does not save the information you typed. Please follow instructions below for saving the forms.

If you are mailing your forms via USPS, please be sure to keep a copy for your records in the event they do not reach our office.

If you choose to e-mail your forms:

  • Fill in the forms and then save the completed form to your computer as a PDF by right-clicking and choosing “Print.”
  • Then Under “Destination,” change to “Save as PDF,” then click “Save.”
  • After the forms have been saved to your computer, check them to be sure the information saved correctly.
  • Attach the files to an e-mail and send to HHCforms@gmail.com.

   

Patient Information Form

Patient Consent Form  (Please read and send in with all forms)

Office Policies (Please read and send in with all forms)

Medical Symptoms Questionnaire

Adult Medical Questionnaire Part 1   (Very important)

Adult Medical Questionnaire Part 2

Diet Assessment Questionnaire

 

The following two forms below should be printed and filled out by hand and brought to your first appointment.

Document in the food journal all that you eat and drink in a 3 day period.

Three Day Food Journal

 

Filling out the "Help us Help you with your Insurance" form will help us to provide you with guidance on billing for services and various routine and specialty lab testing the Doctor may order.

          Help us Help you with your Insurance

Below we provided an instruction checklist for your first appointment. We suggest you print it and use it as a reference guide in preparing for your visit.

 Preparing for your visit with Dr. Bernstein

The following two forms may be filled out periodically to monitor progress:

Medical Symptoms Questionnaire

Diet Assessment Questionnaire

 

 

 

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