APPOINTMENT REQUEST FORM & FEE SCHEDULE
Arrowhead Wellness Center
 
*** IMPORTANT ! PLEASE FOLLOW INSTRUCTIONS ***
WE CANNOT FACILITATE APPOINTMENTS WITH OUT A SIGNED APPOINTMENT REQUEST FORM,
FINANCIAL POLICY FORM, HISTORY FORM, CONSENT FORM
IMPORTANT NOTE: WE'RE WORKING IN A TEMPORARY LOCATION UNTIL WE FIND A SUITABLE REPLACEMENT FACILITY SINCE OUR OLD BUILDING WAS SOLD.
WE'RE LOCATED INSIDE BORMANN STUDIOS UPSTAIRS IN THE BLUE JAY MALL NEXT TO JENSENS MARKET & STARBUCKS. BY APPOINTMENT ONLY.
 
Consent Form / HealthHistory / Financial Policies & Terms
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. IF YOU'RE USING TV ONLINE SERVICE, PRINT THE FORMS OUT AND FILL OUT BY HAND NOTE: USING A 75-80% ON YOUR PRINTER PAGE SET UP WHEN PRINTING WILL HELP LIMIT THE NUMBER OF PAGES IT PRINTS ON.
(PLEASE CHECK THE BOX BELOW)
I have read and understand the Financial Policies& Agree to the terms and conditions. (initials) Financial Policies & Terms
PERSONAL INFORMATION
 Name:
  Today's Date:
 Telephone:
  Cell:
 FAX:
 Address:
  City:
State: Zip:
 E-Mail:
  Confirm E-Mail :
 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 -- "X ")
SELECT ( X )
  NEW PATIENT OFFICE APPOINTMENTS ( ** Overtime billed at $1.00 per min. )   FEE
 
 
New Patient Quantum Energy Information Comprehensive with both Drs.Bormann & McCormick
( wear comfy clothes & wear or bring shoes with a heel like tennis shoes--no sandles or flip flops )
BLITZKREIG !! We clear our schedule to focus all DAY on your needs. Concentrated, Focused Effort to achieve results not possible in multiple-months of hit-and-miss treatment.
Includes an In-depth Case/ Records Review, History & Consultation. Then, through the BioMatrix, using our unique specially developed form of clinical applied kinesology, Dr.Bormann & Dr.McCormick both do an incredibly detailed Quantum Energy Information Physical Exam and evaluation and then apply treatment immediately as we identify things in the order the body instructs. We also may use Photo therapy with Cold Lasers, LEDs , Ultrasound, Plasma Frequency Generators, Ultrasound, Far Infrared Light, Impact® device, Scenar Energy Device, Lymph Massage with Lymphstar Pro, etc with NO ADDITIONAL CHARGE. We do a full compatibility testing of supplements, prescriptions and other compounds free of charge.Remember to bring them along. We also may discuss nutritional & dietary concerns, natural hormone balancing, polypeptide / amino acids, enzyme therapy, homeopathics, nutraceuticals, therapeutic equipment, stress management techniques, etc. (no purchases of products are required to use our services). We also perform any necessary structural work or physiological work such as myofacial release, massage, adjustsments, etc. also unless contraindicated.
 
* Note: When using Quantum Informational methods as the basis for reading and determing treatments, none of us (including the patient) knows what the body is going to reveal until we start working, so please be patient as we endeavor to ferret out underlying issues and address them in the manner the body indicates. It's like peeling the layers of an onion...IT IS A FUN, IMAGINATIVE AND DIFFERENT WAY OF WORKING. We're dealing with energy patterns and subconscience cellular perceptions and information...we don't want to limit ourselves to some disease tag. OUR GOAL IS TO FIND INFORMATIONAL ERRORS AND HELP CORRECT THEM USING FOCUSED INTENT TO HELP THE BODY TO HEAL ITSELF. We believe it is not necessary to keep the patient coming back for months of treatments when concentrated effort can produce profound results with a short concentrated effort, which cna reduce or eliminate the need to come back at all. We take breaks as needed to eat etc. and keep going until the body indicates it's done. We may need a few days or only one...we never know.
 
 
$125 per hr./ up to 8 hrs.per day
Intensive All Day Work Sessions
with bathroom & meal breaks.
 
(Cost Example: 10 hrs. x $125 = $1250)
 
A Non-refundable reservation retainer is required in advance to block the dates of $100. We apply the $100 toward fee totals.
 
We suggest allowing time for 2 work days and then leave early if we finish earlier. Serious longstanding cases can take as much as 10 hrs. per day and 2-3 days.
 
*** APPT. RETAINER BELOW
 
New Patient Basic Office Visit (In-depth Records& Case Review w/Consent, History, Consultation, Plan, etc.)
  $265.00 (up to 2 hrs)
New Patient Salivary Hormone Breif Consult Only : This is our consultation fee only. If we determine a full consultation is needed to serve the client properly, that is scheduled separately and this fee is applied toward the full New Patient Consult Fee. Lab Test Kits are Free and include special lab tubes, Test Requisition Form, and Instructions. Lab Fees are paid separate since each test is priced differently. Each item tested is $35. Details are defined on our webpage Saliva Tests
 
$125.00
$50 per 1/2 hr. follow up

 
Quantum Energy Compatibility Testing Only. Quantum Informational testing of supplements, medications, medical procedures, clinical tests & modalities, foods, lifestyle issues, relationships, and anything else the patient wants to know which would be useful in decision making.
  $ 20.00
EUROPA CLINIC New Patient Consult (Clinic is in Tijuana, Mex.) Includes Indepth Case & Records Review, Detailed History, Consultation, Scheduling any necessary Labs, Info. about Lodging and Transport, etc. -- Note: additional tests may be requested by the physicians which are not included in these fees. 
 
 $325.00 (up to 2 hrs)
   EXISTING PATIENT OFFICE VISIT FEES     FEE
Existing Patient Basic Office Visit without Quantum work
$55.00 (up to 30 min.)
Existing Patient Quantum Energy Evaluation & Resolution w/ both Dr.B.& Dr.Mc
 
$125.00/ hr.for both docs
   VIRTUAL APPOINTMENTS (PHONE, INTERNET, FAX) Patient Calls Us at Appointment Time     FEE
 
New Patient Phone Consultation (In-depth History, Case & Records Review, Consultation)
   $250.00 (up to 2 hrs.)
 
 New Patient Virtual Salivary Hormone Breif Consultation Only This is our consultation fee only. If we determine a full consultation is needed to serve the client properly, that is scheduled separately and this fee is applied toward the full New Patient Consult Fee. Lab Test Kits are Free and include special lab tubes, Test Requisition Form, and Instructions.Lab Fees are paid separate since each test is priced differently. Each item tested is $35. Details are defined on our webpage Saliva Tests
   $165.00
 
  EUROPA CLINIC New Patient Phone Consult (In-depth Case & Records Review, History, Consultation, Candidacy Labs if needed, Border Info., Lodging, Meal Options, Treatment Schedules, Transportation, etc.)    $300.00 (up to 2 hrs.)
   Existing Patient Phone Consultation    $50.00 (up to 30 min.)
   
 

NON-QUANTUM APPOINTMENT FEE TOTAL

THIS DOES NOT INCLUDE NEW PATIENT QUANTUM ENERGY VISITS. SEE BELOW. 

   $
 

*** NEW PATIENT QUANTUM ENERGY COMPREHENSIVE APPT. RETAINER

NON-REFUNDABLE RETAINER TO RESERVE APPOINTMENT DATES $100.00 

   $***
 

 NOTE: If using a Credit Card, there is a 3% Admin.Fee. Multiply Fee Total by 3% >>>

 
 $
   AMOUNT DUE:  
 $
 

TOTAL DUE: 

 
 $
PAYMENT INFORMATION: PLEASE SELECT ONE -- "X" & PLEASE TYPE IN ALL CAPS
Patient Name Telephone Date
VISA MASTERCARD DISCOVER POSTAL MONEY ORDER BANK DRAFT CASH DISCOUNT (3%)
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 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 HISTORY AND SIGNED CONSENT & FINANCIAL POLICY STATEMENT.
ALL PERTINENT MEDICAL RECORDS SHOULD ALSO BE SENT TOGETHER WITH THESE FORMS.
 History Form
 Consent Form
  Financial Policies & Terms
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. EMAIL-- 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.
©1994-2009 Arrowhead HealthWorks ™ P.O.Box 3668, Crestline, CA 92325
(909) 338-3533 / FAX (909) 338-3743
E-mail: dbormann @arrowheadhealthworks.com *ARROWHEADHEALTHWORKS.COM