Forms and Handouts

Welcome to the Advanced Healing Center of Orange 

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

Natural Health Consultation Forms

1. Please print and complete the five (5) forms below. 

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/tests as soon as they are available — info @ advancedhealing .com. If you have not emailed everything before your appointment, bring everything with you to the appointment.

3. If you arrive without your completed forms, your appointment WILL be rescheduled, and you may be subject to a missed appointment fee.

Natural Health Forms:

  1. Policies and Fees Please read every policy thoroughly. Do not just initial this document w/o reading it thoroughly.   
  2. Credit Card Authorization Form
  3. Health Consultant Status Form
  4. Metabolic Assessment Form
  5. Three-Day Food Diary (Print out just one page if your appointment is within the next 48 hours). Include ALL supplements and medications.
  6. (Only if you are 65 or older) Social Frailty Index – This tool can be used to predict longevity and identify at-risk individuals who could benefit from measures that address the social issues affecting their health.
  7. Please DO NOT print this form unless you would like a copy for your records. NOTICE OF PRIVACY PRACTICES – HIPAA. I am required by law to provide this to you. Read through it if you like. These are your privacy rights as a patient.  

 

Chiropractic Forms

Chiropractic Patient Forms

  1. Policies and Fees Please read every policy thoroughly. Do not just initial this document w/o reading it thoroughly.
  2. Chiropractic New Patient Form
  3. Chiropractic Informed Consent Form (Print, read, and bring in with you “unsigned”)
  4. Realistic Expectations and How To Communicate With Dr. Ettinger (Print, fill out, and bring in with you)
  5. *You DO NOT need to print this form unless you would like a copy for your records. NOTICE OF PRIVACY PRACTICES – HIPAA. I am required by law to provide this to you. These are your privacy rights as a patient. 

 

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, etc.), then the quality of care and potential outcome is virtually identical to a patient being seen in my office.

Distance Client 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. Credit Card Authorization Form
  6. *You DO NOT need to print this form unless you would like a copy for your records. NOTICE OF PRIVACY PRACTICES – HIPAA. I am required by law to provide this to you. These are your privacy rights as a patient.  

 

Office Handouts:

Cancer

Electrolytes (Sodium, Potassium, Calcium, Chloride…)