Forms and Handouts

Welcome to the Advanced Healing Center of Orange 

“Death is certain, but life is not. In life, the only thing we have control over is our character and the choices we make. You either pay a biologic toll because of your choices, or you gain a biologic benefit because of your choices.” Dr. Marcus Ettinger

Natural Health Consultation Forms

1. Please print and fill out the first (4) forms under the heading, “Natural Health Forms.” Form #5 is your privacy rights as a patient. 

2. THIS IS VERY IMPORTANT: All of your forms MUST be filled out, COMPLETELY, and brought with you to your new patient appointment. If possible, please scan and email the forms/labs/test as soon as you have them available – info ( @ ) advancedhealing ( . ) com. Also, please bring all pertinent reports and/or laboratory tests with your paperwork. If you arrive without your forms completely filled out, your appointment WILL be rescheduled and you may be subject to a missed appointment fee. Please see form #1 for more details.

Natural Health Forms:

  1. *Policies and Fees Please read every policy thoroughly. Do not just initial this document w/o reading it thoroughly. I am a one-man show and I need to enforce every policy, if violated, to keep the practice running smoothly.  
  2. *Health Consultant Status Form
  3. *Metabolic Assessment Form
  4. *Three-Day Food Diary (Print out just one page if your appointment is within the next 48 hours). Include ALL supplements and medications.
  5. *YOU DO NOT NEED TO PRINT THIS OUT. NOTICE OF PRIVACY PRACTICES – HIPAA. I am required by law that I offer this to you. These are your privacy rights as a patient. 

Chiropractic Forms

Chiropractic Patient Forms

  1. *Chiropractic New Patient Form (Print, fill out, and bring in with you)
  2. *Chiropractic Informed Consent Form (Print, read, and bring in with you “unsigned”)
  3. *Email, Phone, and Zoom Policies and Fee Schedule 05-24-2020 (Print, fill out, and bring in with you)
  4. *YOU DO NOT NEED TO PRINT THIS OUT. NOTICE OF PRIVACY PRACTICES – HIPAA. I am required by law that I offer this to you. These are your privacy rights as a patient. 

Additional Forms: (ONLY if requested by Dr. Ettinger)

Distance Client Forms:

Becoming a long‐distance patient does not detract from the quality of care. If all of the bases are covered, in the beginning (labs, consultation, history, forms…), then the quality of care and potential outcome are virtually identical to a patient being seen in my office.

Distance Client Program Application, Instructions, Costs:

  • Distance Client Program revised 01-January-19 (If for some reason you can’t open the forms on the distance client application, they are all in the “Natural Health Forms” section above, with the red asterisk next to them. You will still need to print out the “Distance Client Application”, fill it out and send it in with all other applicable forms and tests. Thank you.

Office Handouts:

Cancer

Electrolytes (Sodium, Potassium, Calcium, Chloride…)