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 )
  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 )
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 Quantum Energy Information Physical Exam and Treatment as we go, in the order the body wants. We focus on the whole person which may include identification and treatment of: Structure / Function Imbalances, Identification and Elimination of Energy signtures emitted by toxins, poisons, chemicals, viruses, bacteria, molds,fungi, allergens, chemicals, heavy metals, radiation, neurotoxins, endotoxins,exotoxins, DNA imprint errors, DNA generational imprints, subsconscious toxic emotional & psychological patterns, outside spiritual influences, stored maladaptive cellular perceptions, etc. which can contribute to manifestation of illness or chronic conditions, addictive patterns, etc. We also may use Photo therapy with Cold Lasers, LEDs , Ultrasound, Plasma Frequency Generators, Ultrasound, Far Infrared Light, Impact® device, etc. at no added charge. We do a full compatibility testing of supplements, prescriptions and other compounds free of charge. Bring them along. We also may discuss nutritional counseling, natural hormone therapies, 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.
* Note: On the Quantum Informational portion of the sessions, 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 says it wants. 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 unethical to keep the patient coming back over and over for months when concentrated effort can produce profound results. 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.
 
 
$140.00 per hr./up to 8 work hrs./day
 
A Non-refundable retainer is required in advance to block the dates of $100 and fee is paid at the end of each day. We credit 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.
(Cost estimate example: 20 hrs. x $140/hr.=$2800) This is for both docs.
 
Whole families are done by special request, however our rate is PER PERSON. Allow 1 day per person min.
 
*** APPT. RETAINER BELOW
 
New Patient Basic Office Visit (In-depth Records& Case Review w/Consent, History, Consultation)
  $265.00 (up to 2 hrs)
New Patient Salivary Hormone Breif Consultation Only (Requires coming into the office for the hormone kit pick up) Test kits are free. This does not include the cost of the Lab Fees which varies depending on the tests selected.  
$145.00 **

 
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 Preliminary New Patient Consult (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 prior to scheduling a patient exam and evaluation at the clinic in TJ. 
 
 $400.00 (up to 3 hrs)
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
 
$135.00/ hr.
   VIRTUAL APPOINTMENTS ( Patient Calls Us at Appointment Time )    
 
PHONE CONSULTATION w/Dr.B. (In-depth History, Case & Records Review, Consultation)
   $250.00** (approx. 2 hrs.)
 
  EUROPA CLINIC New Patient Coordinators Consult (In-depth Case & Records Review, History, Consultation, Candidacy Labs if needed, Border Info., Lodging, Meal Options, Treatment Schedules, Transportation, etc.)    $400.00** (up to 3 hrs.)
   PHONE CONSULT FOLLOW UP CALLS    $50.00 per 1/2 hr.
   
 

FEE TOTAL

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

   $
 

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

 
 $
   AMOUNT DUE:  
 $
       
 

*** NEW PATIENT QUANTUM ENERGY COMPREHENSIVE APPT. RETAINER

NON-REFUNDABLE RETAINER TO RESERVE APPOINTMENT DATES $100.00

 
$***
 

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: Zip CodePhone
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 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 -- Please Print this form at 80% or Use Shrink to Fit in Printer Option Window Prior to Sending to Insure We Get All Your Info. Many times we loose info. because it runs off pages printed off Websites. Thanks !
©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