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In order to provide you the best possible wellness care, please complete this form

Patient Data

Mailing Address

Current Health Challenges/Complaints

Health Insurance Information (if you would like our office to check on your health insurance benefits)

Please note that due to Dr. Brennan Huls' unique membership fee system, he is unable to accept 3rd party payment in any form. If you desire to use your health insurance you will be under the care of Dr. Terrie Huls.

If your health challenges could be the result of an auto accident, please provide:

Signatures will be completed in the office

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Medical History

Have you ever experienced:

Family History

Lifestyle Habits

Have you ever suffered from:

Health Status Questionnaire

Physical Life

Mental/Emotional State

Chemical/Nutritional Life

Stress Evaluation

Life Enjoyment