thank you for choosing us for your wellness needs

Thank you for choosing us for your wellness needs. You are about to engage in a journey that will provide an opportunity to improve your health. It could even change your life. Every patient is evaluated for their chief complaint based on need regarding level of health. Only after careful consideration of the information gathered at your exam, will it be known if you are a

candidate for care. Options will be discussed at the special report (2nd) visit and proper referrals will be made if necessary. Any questions you have about the nature of your care can be asked during your consultation / exam (1st) visit.

What I DO: ---------The Science and Art:---------

● Muscle testing – Strength, Functional Nerve/Reflex ● Chiropractic Adjustments – Instrument/Manual ● Palpation/Range of Motion ● Nutritional/Dietary Counsel

● Neurological Testing, Therapies & Rehabilitation (QN) including: Hot/Cold, Light, Taping

● Reflexive Stress Therapy (RST/NET) ● Body-Mind/Spirit exploration: may include prayer,

emotion, spiritual matters to address physiology ---------------------------The Philosophy: ---------------------------

o We are a spiritual being held in a physical body; where issues of a physical matter may or may not have a physical correction but also an emotional or spiritual one.

o The body has the ability to heal and is the master at doing so when it communicates in all areas and systems without interruption: body-mind and spirit.

o The practitioner is a facilitator, not the healer. We don’t FIX anything but rather assist the individual to become aware of weaknesses discovered in their system, then facilitate correction.

o Healing takes time. Being patient with your process without forcing it is the preferred and most efficient way to bring change. Forcing issues can actually slow progress in some cases.

o ADIO – we develop and heal from above, down and inside, out.

o With a little guidance and proper information, patients can take responsibility for choosing what’s best for their health. Our goal is to empower each to learn awareness of their issues and make their best choice. It is the responsibility of the patient to comply with recommendations to get the best result.

What I DO NOT: Counselor of the mind – All emotion starts as a physiological response to a stimulus. Although difficult situations may be discussed, it is minimal and only to arrive at an idea that generates physiological response. We do not seek to change behavior. Patients are encouraged to journal for personal benefit and by doing so, may reveal additional patterns where RST/NET will help. When necessary, referrals to proper counselors will be provided. Pastor/theologically trained - Although I am a follower of Jesus Christ, I am not a spiritual advisor or pastor. Any and all experiences shared are from the personal perspective of a Christian world view. I do not hide my beliefs nor seek to convert followers. While I respect those of other faiths, I do not have personal knowledge of those and have no intention to offend when information may conflict.

What’s different about this care? Chiropractic is the science, philosophy and art of finding and correcting the subluxation. Since the nervous system is central to the health of the individual, assessing the dysfunction of it first and locating what changes as a result, enables us to navigate the misalignments in the spine from the inside out. Seeking to bring awareness to the system where interference has been ignored, allows a more efficient and even permanent change, causing lasting resolution. It’s the why behind the misaligned. (see next page triad of health & video links)

Resonate Wellness Chiropractic PATIENT INFORMATIONDenise Parker, DC :: [email protected] :: 200 N Mill St. :: Lewisville, TX 75057 :: 972 -951-9355

Pt file# Doctor(init)Signature/Date

Must see information to provide understanding about Dr. Parker’s

approach to care:

NeuroEmotional Technique: (3 videos)

https://www.netmindbody.com/more-information/for-body-oriented-practitioners/

Quantum Neurology: (1 video) https://quantumneurology.com/

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Patient Notes: Questions to ask on my first visit about my care and the techniques used:

Please do not sign attached consent forms unless your questions have been satisfied

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https://www.netmindbody.com/more-information/for-body-oriented-practitioners/

https://quantumneurology.com/



Please complete the following information as completely as possible.

Name: __________________________________________ Date: ________________ Birthday (M/D/Y): ____________

Address/City/Zip: _________________________________________________________________________________

Email:___________________________________________________________ Age: _________ Gender: ____________

Phone: __________________________________________ Cell: ____________________________________________

Marital status: _____________ Minor Children?: No/Yes/#______ Do you have Medicare Part B: No/Yes (ask for form)

Occupation/Employer ________________________________________ Driver’s License #/State: __________________

Emergency Contact/Relationship: _________________________________________ Phone #: ____________________

Do you wish to receive periodic communication promoting events/info from Dr. Parker? No/Yes - Text/email

How did you hear about this clinic: Drove by/Website/Online Search/Community Ad/Referral…Who may we thank for

referring you? ________________________ Do you have a religious/spiritual practice? If so, what ________________

MAIN HEALTH CONCERNS My usual health is: • Excellent • Good • Fair • Poor

Please list by importance, your current chief concerns/reasons for seeking care:

1. 3.

2. 4.

When did the symptoms appear for this (#) condition? ____________________________________________________

________________________________________________________________________________________________

(Please circle appropriate responses) Accident or Reoccurrence? No/Reoccurrence /Accident-Auto, Work, Home. If so, has it been

reported? Insurance company, Employer, Work Comp? Does any interfere with your: Work / Sleep / Recreation / Daily

routine / other ______________________________ Are any of the conditions getting worse(#)? __________________

Are the following painful or difficult? Sitting / Standing / Walking / Lying / Bending / Lifting / Other ________________

How often do you experience symptoms from these conditions(#)? _________________________________________

What are you unable to do because of this condition? ____________________________________________________

Is it (#) constant or does it come and go? _______________________________________ Rate any pain 1-10 ________

Where do you feel the (#)?: (please mark on the diagram)

Do you feel any of the following: Numbness / Throbbing /

Tingling / Weakness / Sharp / Ache / Burning / Swelling /

Stiffness / Dull / Cramping

How does your condition make you feel?

____________________________________________

Have you been treated for this condition previously?

No / Yes / by: Medication / Surgery / Chiropractic /

Nutrition / Acupuncture / Other __________________

____________________________________________

Date of last: Physical _________, X-Rays __________,

MRI/CT/Ultrasound _________,Blood work ________,

Urine ________

Vaccinations: fully vaccinated / some vaccines / travel

vaccines (ie. Hepatitis) / flu shot regularly / no vaccine /

don’t know / don’t remember



FAMILY & PERSONAL HISTORY Were you adopted?: • No / if Yes •Access fam med history? • N/Y

Please indicate any personal current (C),past (P) or family history (FH) of the following conditions:

Condition C P F

H Condition C P

F

H Condition C P

F

H Condition C P

F

H

AIDS Cataracts Intestinal Disorders

Psychiatric care

Alcoholism Chemical Dependency

Kidney Disease Rheumatic fever

Allergies Diabetes: Type 1 / 2 Liver Disease Rheumatoid Arthritis

Allergy shots Eczema Measles Scarlet fever

Anemia Emphysema Mental illness Stroke

Anorexia Epilepsy Miscarriage Suicide attempt

Appendicitis Glaucoma Mononucleosis Thyroid Problem

Arthritis Goiter Multiple Sclerosis Tonsillitis

Asthma Gout Osteoporosis Tuberculosis

Autoimmune Heart Disease Pacemaker Tumors

Bleeding disorder Hepatitis Parkinson’s Typhoid fever

Blood pressure High/Low

Hernia Pinched nerve Ulcers

Breast lump Herniated Disc Pneumonia Vaginal infections

Bronchitis Herpes Polio Venereal disease

Bulimia High Cholesterol Prostate problem Whooping cough

Cancer Inflammatory Disease

Prosthesis

● List major childhood illnesses: (ear infections, strep throat, tonsillitis, chicken pox, measles, etc.) _______________

_____________________________________________________________________________________________

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● Major mental/emotional traumas: (loss of loved one, divorce, career change, miscarriage, major disease, etc.) ____

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● List any real or suspected allergies/sensitivities to drugs, food, alcohol, caffeine, chemicals, perfumes, smoke,

environment, or other: __________________________________________________________________________

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Please list any hospitalizations, surgeries, major accidents/injuries, x-rays, CAT scan, MRIs, EKGs, etc., any age/time

Description Date

Falls _______________________________________________________________ ___________________

Head injuries _______________________________________________________________ ___________________

Broken Bones _______________________________________________________________ ___________________

Auto Accidents _______________________________________________________________ ___________________

Surgeries _______________________________________________________________ ___________________



The nature of your responses to the following questions will go a long way in assisting how I can best help you. Your

time, thoughtfulness and honesty in completing this overview are appreciated. Use a separate sheet if necessary.

1. What do you know about wholistic chiropractic care?

2. What expectations do you have from this initial visit?

3. What are your long term expectations about working

with Dr. Parker and her office?

4. What expectations do you have of Dr. Parker personally

as your wellness provider?

5. Indicate your level of commitment to address any

underlying issues related to your current concerns?

0% -----------25% ----------- 50% -----------75% -----------100%

6. What do you currently do regularly that may support

your health?

7. Do you feel you are fulfilling your purpose in life? If no,

what is standing in your way?

8. What do you currently do regularly that may be self-

destructive to your health?

9. What are the potential problems that might hinder you

when following Dr. Parker’s recommendations for you?

Please list the name of any medications/supplements you currently take and for what conditions, add additional paper if necessary

Med/Sup Name Condition

M/S

M/S

M/S

M/S

M/S

M/S

M/S

M/S



Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Category I Feeling that bowels do not empty completely 0 1 2 3 Lower abdominal pain relieved by passing stool or gas 0 1 2 3 Alternating constipation and diarrhea 0 1 2 3 Diarrhea 0 1 2 3 Constipation 0 1 2 3 Hard, dry, or small stool 0 1 2 3 Coated tongue or “fuzzy” debris on tongue 0 1 2 3 Pass large amount of foul-smelling gas 0 1 2 3 More than 3 bowel movements daily 0 1 2 3 Use laxatives frequently 0 1 2 3

Category II Increasing frequency of food reactions 0 1 2 3 Unpredictable food reactions 0 1 2 3 Aches, pains, and swelling throughout the body 0 1 2 3 Unpredictable abdominal swelling 0 1 2 3 Frequent bloating and distention after eating 0 1 2 3 Abdominal intolerance to sugars and starches 0 1 2 3

Category III Intolerance to smells 0 1 2 3 Intolerance to jewelry 0 1 2 3 Intolerance to shampoo, lotion, detergents, etc. 0 1 2 3 Multiple smell and chemical sensitivities 0 1 2 3 Constant skin outbreaks 0 1 2 3

Category IV Excessive belching, burping, or bloating 0 1 2 3 Gas immediately following a meal 0 1 2 3 Offensive breath 0 1 2 3 Difficult bowel movement 0 1 2 3 Sense of fullness during and after meals 0 1 2 3 Difficulty digesting fruits and vegetables; undigested food found in stools

0 1 2 3

Category V Stomach pain, burning, or aching 1-4 hours after eating 0 1 2 3 Use antacids 0 1 2 3 Feel hungry an hour or two after eating 0 1 2 3 Heartburn when lying down or bending forward 0 1 2 3 Temporary relief by using antacids, food, milk, or carbonated beverages

0 1 2 3

Digestive problems subside with rest and relaxation 0 1 2 3 Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine

0 1 2 3

Category VI Roughage and fiber cause constipation 0 1 2 3 Indigestion and fullness last 2-4 hours after eating 0 1 2 3 Pain, tenderness, soreness on left side under rib cage 0 1 2 3 Excessive passage of gas 0 1 2 3 Nausea and/or vomiting 0 1 2 3 Stool undigested, foul smelling, mucous like, greasy, or poorly formed

0 1 2 3

Frequent urination 0 1 2 3 Increased thirst and appetite 0 1 2 3

Category VII Greasy or high-fat foods cause distress 0 1 2 3 Lower bowel gas and/or bloating several hours after eating 0 1 2 3 Bitter metallic taste in mouth, especially in the morning 0 1 2 3 Burpy, fishy taste after consuming fish oils 0 1 2 3 Difficulty losing weight 0 1 2 3 Unexplained itchy skin 0 1 2 3 Yellowish cast to eyes 0 1 2 3 Stool color alternates from clay colored to normal brown 0 1 2 3 Reddened skin, especially palms 0 1 2 3 Dry or flaky skin and/or hair 0 1 2 3 History of gallbladder attacks or stones 0 1 2 3 Have you had your gallbladder removed? Yes / No

Category VIII Acne and unhealthy skin 0 1 2 3 Excessive hair loss 0 1 2 3 Overall sense of bloating 0 1 2 3 Bodily swelling for no reason 0 1 2 3 Hormone imbalances 0 1 2 3 Weight gain 0 1 2 3 Poor bowel function 0 1 2 3 Excessively foul-smelling sweat 0 1 2 3

Category IX Crave sweets during the day 0 1 2 3 Irritable if meals are missed 0 1 2 3 Depend on coffee to keep going/get started 0 1 2 3 Get light-headed if meals are missed 0 1 2 3 Eating relieves fatigue 0 1 2 3 Feel shaky, jittery, or have tremors 0 1 2 3 Agitated, easily upset, nervous 0 1 2 3 Poor memory/forgetful 0 1 2 3 Blurred vision 0 1 2 3

Category X Fatigue after meals 0 1 2 3 Crave sweets during the day 0 1 2 3 Eating sweets does not relieve cravings for sugar 0 1 2 3 Must have sweets after meals 0 1 2 3 Waist girth is equal or larger than hip girth 0 1 2 3 Frequent urination 0 1 2 3 Increased thirst and appetite 0 1 2 3 Difficulty losing weight 0 1 2 3

Category XI Cannot stay asleep 0 1 2 3 Crave salt 0 1 2 3 Slow starter in the morning 0 1 2 3 Afternoon fatigue 0 1 2 3 Dizziness when standing up quickly 0 1 2 3 Afternoon headaches 0 1 2 3 Headaches with exertion or stress 0 1 2 3 Weak nails 0 1 2 3



Category XII Cannot fall asleep 0 1 2 3 Perspire easily 0 1 2 3 Under high amount of stress 0 1 2 3 Weight gain when under stress 0 1 2 3 Wake up tired even after 6 or more hours of sleep 0 1 2 3 Excessive perspiration or perspiration with little or no activity 0 1 2 3

Category XIII Edema and swelling in ankles and wrists 0 1 2 3 Muscle cramping 0 1 2 3 Poor muscle endurance 0 1 2 3

Cat XIII Continued Frequent urination 0 1 2 3 Frequent thirst 0 1 2 3 Crave salt 0 1 2 3 Abnormal sweating from minimal activity 0 1 2 3 Alteration in bowel regularity 0 1 2 3 Inability to hold breath for long periods 0 1 2 3 Shallow, rapid breathing 0 1 2 3

Category XIV Tired/sluggish 0 1 2 3 Feel cold―hands, feet, all over 0 1 2 3 Require excessive amounts of sleep to function properly 0 1 2 3 Increase in weight even with low-calorie diet 0 1 2 3 Gain weight easily 0 1 2 3 Difficult, infrequent bowel movements 0 1 2 3 Depression/lack of motivation 0 1 2 3 Morning headaches that wear off as the day progresses 0 1 2 3 Outer third of eyebrow thins 0 1 2 3 Thinning of hair on scalp, face, or genitals, or excessive hair loss 0 1 2 3 Dryness of skin and/or scalp 0 1 2 3 Mental sluggishness 0 1 2 3

Category XV Heart palpitations 0 1 2 3 Inward trembling 0 1 2 3 Increased pulse even at rest 0 1 2 3 Nervous and emotional 0 1 2 3 Insomnia 0 1 2 3 Night sweats 0 1 2 3 Difficulty gaining weight 0 1 2 3

Category XVI Diminished sex drive 0 1 2 3 Menstrual disorders or lack of menstruation 0 1 2 3 Increased ability to eat sugars without symptoms 0 1 2 3

Category XVII Increased sex drive 0 1 2 3 Tolerance to sugars reduced 0 1 2 3 “Splitting” - type headaches 0 1 2 3

Category XVIII (Males Only) Urination difficulty or dribbling 0 1 2 3 Frequent urination 0 1 2 3 Pain inside of legs or heels 0 1 2 3 Feeling of incomplete bowel emptying 0 1 2 3 Leg twitching at night 0 1 2 3

Category XIX (Males Only) Decreased libido 0 1 2 3 Decreased number of spontaneous morning erections 0 1 2 3 Decreased fullness of erections 0 1 2 3 Difficulty maintaining morning erections 0 1 2 3 Spells of mental fatigue 0 1 2 3 Inability to concentrate 0 1 2 3 Episodes of depression 0 1 2 3 Muscle soreness 0 1 2 3 Decreased physical stamina 0 1 2 3 Unexplained weight gain 0 1 2 3 Increase in fat distribution around chest and hips 0 1 2 3 Sweating attacks 0 1 2 3 More emotional than in the past 0 1 2 3

Category XX (Menstruating Females Only) Perimenopausal Yes / No Alternating menstrual cycle lengths Yes / No Extended menstrual cycle (greater than 32 days) Yes / No Shortened menstrual cycle (less than 24 days) Yes / No Pain and cramping during periods 0 1 2 3 Scanty blood flow 0 1 2 3 Heavy blood flow 0 1 2 3 Breast pain and swelling during menses 0 1 2 3 Pelvic pain during menses 0 1 2 3 Irritable and depressed during menses 0 1 2 3 Acne 0 1 2 3 Facial hair growth 0 1 2 3 Hair loss/thinning 0 1 2 3

Category XXI (Menopausal Females Only) How many years have you been menopausal? ____yrs Since menopause, do you ever have uterine bleeding? Yes / No Hot flashes 0 1 2 3 Mental fogginess 0 1 2 3 Disinterest in sex 0 1 2 3 Mood swings 0 1 2 3 Depression 0 1 2 3 Painful intercourse 0 1 2 3 Shrinking breasts 0 1 2 3 Facial hair growth 0 1 2 3 Acne 0 1 2 3 Increased vaginal pain, dryness, or itching 0 1 2 3

Do you get headaches? • No, • Yes How would you describe

them?: • Migraine, • Visual disturbance, • Nausea, •

Tension, • Vomiting, • Allergy Related, • Aura, • Light

sensitive, • Ocular migraine; How often? _____________

Are you on birth control? • No, • Yes

Are you pregnant? • No, • Yes - due date? _____________

Have you used hormone replacement therapy? • No, • Yes

Have you taken antibiotics? • No, • Yes When? _________



How many/often:

Alcoholic beverages/wk? __________________________

Caffeinated beverages/day? _______________________

Times do you eat fish/wk __________________________

Times do you eat out/wk? _________________________

Times do you work out/wk? _______________________

Times do you eat raw nuts/seeds/wk? _______________

Are you Vegetarian • No, • Yes Height: ____________

Do you skip meals • No, • Yes Weight: ___________

Do you crave sugar • No, • Yes Blood Type: __________

How much sugar do you eat? • Little • Moderate • High

worst foods typically consumed ____________________

______________________________________________

healthiest foods typically consumed _________________

______________________________________________

Do you crave certain foods? • No, • Yes – what foods? ___

______________________________________________

Do you have energy crashes? • No, • Yes; Time/s: _______

______________________________________________

Rate your stress (1-10) ave/wk? _____________________

__________________________________________________________________________________________ Sign/Print I am: • Patient, • Parent/Guardian of: ______________________________ Date

- - - - - - - - - - - - - - - - - - For OFFICE USE only – Do not write below this line - - - - - - - - - - - - - - - - - -



INFORMED CONSENT AND REQUEST FOR CHIROPRACTIC CARE As a patient, I have the right to be informed about my health condition(s) and recommended treatments. Dr. Parker or an authorized agent of Resonate Wellness Chiropractic will discuss the potential benefits, risks and hazards involved. After signing this consent form, I understand I can withdraw consent at any time. Chiropractic care is the science, philosophy and art of locating and correcting subluxations (interference) and such, is oriented toward improvement of nervous system function relative to range-of-motion, muscular, and visceral aspects. Basic chiropractic philosophy teaches that subluxation is caused by structural, mental and chemical interference. Because each of those areas cause subluxation, the subluxation is the symptom. It is for this reason other areas are explored outside of the traditional approach to care and is only done so to elicit a response to reveal the subluxation/interference. Although difficult situations may be discussed, it is minimal and only to arrive at the concept to generate a physiological response. It is on no way assumed to be a replacement for professional counseling and/or spiritual guidance. These situations may include talk of emotions and/or spiritual matters as they relate to generating physiology. There are some risks that may be associated with treatment, in particular you should note: 1. While rare, some patients have experienced rib fractures or muscle

and ligament sprains or strains following treatment using manual adjustments; There have been rare reported cases of disc injuries following cervical and lumbar spinal adjustment although no scientific study has ever demonstrated such injuries are caused, or may be caused, by spinal or soft tissue manipulation or treatment There have been reported cases of injury to a vertebral artery following osseous spinal manipulation. Vertebral artery injuries have been known to cause a stroke, sometimes with serious neurological impairment and may, on rare occasion, result in paralysis or death. The possibility of such injuries resulting from cervical spine manipulation is extremely remote

2. As with the practice of medicine, the practice of chiropractic is not an exact science, but relies upon information related by the

patient, information gathered during examination, and the Doctor’s interpretation thereof, as well as the Doctor's judgment and expertise in working with like cases.

3. It is not reasonable to expect my chiropractor to be able to anticipate, or explain, all possible risks and complications of a given procedure on any particular visit and I wish to rely on the Doctor to exercise professional judgment during the course of any procedures, which she feels at the time to be in my best interest.

4. An undesirable result, or side effect, does not necessarily indicate an error in judgment or an improper treatment and may indicate an improved ability to express responses interpreted by my nervous system.

Osseous adjustments and soft tissue manipulations have been the subject of government reports and multi-disciplinary studies conducted over many years and have demonstrated it to be highly effective treatment of spinal conditions including improvement of: 1. General pain and loss of mobility, headaches and other related

symptoms and contributes to your overall wellbeing. 2. The risk of injuries or complications from treatment is substantially

lower than that associated with many medical or other treatments, medications, and procedures given for the same symptoms.

_____ I recognize that even the gentlest therapies may potentially have complications in very young children, in the elderly, or in those on multiple medications. Hence, the information I have provided is complete and inclusive of all health concerns and medications, including over-the-counter medications, supplements, and herbs. _____ I recognize that Dr. Denise Parker is not a counselor or pastor and only draws from personal and professional clinical experience to bring awareness to my system. I also agree to be evaluated further by appropriate professionals outside her training should the need arise or a recommendation is made. _____ There have been no promises implied or otherwise, of a cure for any symptom, disease or condition as a result of treatment in this clinic. I have had the opportunity to ask questions and receive answers regarding the treatment. _____ I understand this is a wellness program and likely is not covered by insurance or Medicare. Dr. Parker does not file claims. I agree to request any additional forms necessary for my personal need. I hereby request and consent to the treatments offered or recommended to me by Dr. Denise Parker and Resonate Wellness Chiropractic, including osseous and soft tissue manipulation. I intend this consent to apply to all my present and future care with Dr. Denise Parker and Resonate Wellness Chiropractic.

____________________________________________________________________________________________________________ Sign/Print I am stating I am: Patient, • Parent/Guardian of: ______________________________ Date

____________________________________________________________________________________________________________ Sign/Print Witness Name Date



CONSENT FOR TRANSMISSION OF PROTECTED HEALTH INFORMATION

BY NON-SECURE MEANS

We are set up with a HIPAA compliant/encrypted e-mail ([email protected]) that protects any information we have within our inboxes. However, once e-mails leave our inbox they are sent by non-secure means. We are also open to exchanging text messages from our office phone. We incorporate security measures to protect the information received to the best of our ability. However, this information is potentially at risk and administrators or technicians may have access to the content of such communications either from our end, or from your own.

Of special consideration are work email addresses. If you use your work email to communicate with us, your employer may access our email communications. There may be similar issues involved in school email or other email accounts associated with organizations that you are affiliated with. Additionally, people with access to your computer, mobile phone, and/or other devices may also have access to your email and/or text messages. Please take a moment to contemplate the risks involved if any of these persons were to access the messages we exchange with each other.

It is your right to receive protected health information via non-secure means, should you consent to authorizing us to do so. If you choose not to provide this authorization, we will restrict communications related to your protected health information to phone calls and in person exchanges.

For details on how to provide us with authorization to use non-secure e-mail and/or text please see the following consent form:

I, the patient and undersigned, AUTHORIZE: Resonate Wellness Chiropractic, Dr. Denise Parker & Staff ::

200 N Mill Street :: Lewisville, TX 75057 TO: TRANSMIT THE FOLLOWING PROTECTED HEALTH INFORMATION RELATED TO MY HEALTH RECORDS AND HEALTH CARE TREATMENT BY THE FOLLOWING NON-SECURE MEDIA:

o All Health related information transmitted from our office: SECURE email ([email protected]) o SMS text message (i.e. traditional text messaging) or other type of “text message.”

Please indicate by initial below: E-mail Text

Information related to the scheduling of appointments or other meetings Information related to billing and payment (including SuperBills) Completed forms, including forms that may contain sensitive, confidential information Information of a therapeutic or clinical nature, including discussion of personal material relevant to my treatment

My health record, in part or in whole, or summaries of material from my health record I have been informed of the risks, including but not limited to my confidentiality in treatment, of

transmitting my protected health information by unsecured means. I understand that I am not required to sign this agreement in order to receive treatment. I also understand that I may terminate this authorization at any time or should I choose to discontinue care. ______________________________________________________________________________________________ Sign/Print I am: • Patient, • Parent/Guardian of: ______________________________ Date



APPOINTMENT POLICY Our goal is to provide quality individualized wellness care in a timely manner. "No-shows," late shows and cancellations inconvenience those individuals who need access to care in a timely manner. We would like to notify you of our office policy regarding missed appointments. This policy enables us to better utilize available appointments for our patients in need of Dr. Parker’s care. Cancellation of an Appointment In order to be respectful of the needs of other patients, please be courteous and call Dr. Parker’s office promptly if you are unable to show up for an appointment. If it is necessary to cancel your scheduled appointment, we require that you call at least 24 hours in advance. Appointments are in high demand, and your early cancellation will give another person the possibility to have access to timely care. How to Cancel Your Appointment To cancel appointments, please call or text 972-951-9355. If no one is available to take your call, you may leave a detailed message on the voice mail or opt to send by text message. If you would like to reschedule your appointment, please leave your phone number. We will return your call and give you the next available appointment time. Please note while necessary measures are taken to secure information sent via text, it is NOT a secure means of communicating personal health information. Please use caution with your private information when choosing this method of communication. Late Cancellations: A late cancellation is considered when a patient fails to cancel their scheduled appointment with a 24 hour advance notice. No Show Policy: A "no-show" is someone who misses an appointment without cancelling it in an adequate manner. A failure to be present at the time of a scheduled appointment will be recorded in the patient's chart as a "no-show.” This includes arriving 10 minutes after your scheduled appointment.

Associated Fees:

“No-Show” – 1st time No Charge

“No-Show” – 2nd time $40

“No-Show” – 3rd time $75 & Possible discharge

Late Cancellations – 1st/2nd time No Charge

Late Cancellations – 3rd or more $40

After hours/weekend/holiday +$25

I have read and understand this missed appointment policy. Any questions I have regarding this policy have been answered.

__________________________________________________________________________________________ Sign/Print I am: • Patient, • Parent/Guardian of: ______________________________ Date

thank you for choosing us for your wellness needs

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