This letter is intended for clients visiting Ricardo Boye, ND.

Transcription

1 This letter is intended for clients visiting Ricardo Boye, ND. Welcome, friends, to The Spa on Green Street! You will discover much along the way about how your body functions and, most importantly, what is required to achieve optimal health and well-being. We welcome any questions you may have during the course of your participation. Please review the following guidelines designed to simplify your visit arrangements: 1. How to Schedule Your Appointment Please call toll-free at (877) (Ricardo Boye s office in Georgia) to schedule your appointment or to ask any questions relating to your care. Appointments are secured with a credit card. If you prefer to pay with a check, your credit card will not be charged. Cancellation Policy: Please give 48 hours notice for any changes or cancellations to avoid any fees. Cancellations of less than 48 hours notice will be billed at the rate of 50% of service fee. Cancellations without any notice will be billed the full amount. Appointment fees are as follows: Initial Consultation 90 minutes $175 Follow-up 60 minutes $ 90 Follow-up 30 minutes $ What Happens at the Conclusion of Your Appointment? Ricardo Boye will send your protocol to The Spa on Green Street following your appointment. Please call the Spa toll-free at (877) and identify yourself as a Texas client to obtain your protocol and schedule your follow-up appointment. The Spa is open Monday through Saturday from 10:00 a.m. to 6:30 p.m. (EST). 3. How to Make Payment Payment for services will be charged at the end of each appointment by using the credit card given at the time of booking, unless otherwise specified. Ground shipping charges will be waived for any product orders over $ However, if a specialized product is requested that we do not carry, you will be responsible for the shipping charge from the third-party vendor. 4. Our Return Policy Returns of unopened product are accepted for spa credit within 30 days of purchase. 5. Location for the Upcoming Houston Visits Ricardo Boye s visits are currently taking place at the Sheraton Suites Hotel, 2400 W. Loop South, near the Galleria. The phone number is Please notify the front desk of your arrival and appointment with Ricardo Boye, and you will be attended to promptly. 6. Additional questions and information Should you have specific questions relating to your health, feel free to call Dr. Boye at (877) or him at rboye@spaongreenstreet.com.

2 Guest Information Today s Date: (Please print) Name: Address: City: State: Zip: Home Phone: Office Phone: Cell Phone: Please circle the number at which you prefer to be contacted: Home Office Cell Occupation: Age: Birth date: Address: How did you hear about us? Who should we contact in the event of an emergency: Name: Relation: Phone Number: Notice of Understanding and Agreement I understand that I am not receiving consultation for medical diagnosis or medical treatment procedures. The services performed at this spa are for the purpose of helping me gain a better understanding of my level of health so that I will have a greater self-awareness and be able to use a self-care program. I understand that the recommendations, discussion, sale of nutritional supplements or homeopathics pertain to the whole body energetic concept of nutrition and do not relate to the treatment of any specific ailment or condition. The appointments do not involve diagnosis, prognostication, treatment or prescription of medicines for illness or disease, or any act which will constitute the practice of medicine in the state of Georgia. I (we) agree to pay for services rendered as the charge is incurred. I release The Spa on Green Street., its owner, its employees, teachers, and contractors from any liability for injury or loss of property. Cancellation Policy In order to best accommodate your requests, we ask that a minimum notice of 24 hours be given for any changes or cancellation. Cancellations of less than 24 hours will be charged a fee equivalent to half the scheduled service total, and Gift Certificates will be reduced to half value. We regret that lack of any notification will result in full billing of your scheduled services. Consent for a Minor or Dependant (if applicable) I do hereby give my full authority and consent to the staff at The Spa on Green Street to assist the guest mentioned below in a self-care program. Guest Signature Date Spouse or Guardian s Signature Date 635 Green Street, N.W. Gainesville, GA (678) (o) (678) (f)

3 Health Questionnaire Guest Name: Date: Thank you for choosing The Healing Arts Spa on Green Street where you will discover much about your health and how your body functions. We welcome any questions you may have during the course of your participation. Below are questions that will assist us in evaluating your health needs. Please check all applicable boxes. Sleep: How is your sleep? restful restless hard to get to sleep wake up often get up during the night bad dreams other: Digestion: How is your digestion? adequate poor acid reflux burp often bloating burning or pain in stomach Exercise: daily 4-5 times per week 2-3 times per week cardiovascular resistance sports enjoy exercising Sunlight: receive daily sunlight outside receive daily sunlight through windows fluorescent lighting in home/work Eyewear: contact lenses glasses just for reading 2-3 hours/day 4-6 hours/day 8+ hours/day Electromagnetic Exposure: watch TV 1+ hours daily work with computers hours talking on phone: hours talking on cell phone: wear a pager wear a headset ride in a truck/car/vehicle 1+ hours daily near electrical equipment for long periods (copy machines, high power lines, etc.) Chemical Exposure: work with chemicals handle chemicals directly chemicals around the workplace smoker recreational drug use, past or present Stress: minimal moderate heavy severe family stress job stress Dental work: silver fillings composites extractions: wisdom, bicuspids, etc. bridgework partial or full dentures gold crowns or inlays

4 stainless steel crowns or inlays porcelain crowns or inlays veneers root canals posts implants temporaries braces bleeding gums sensitive teeth bad bite new cavities dental surgery describe: need for further dental work describe: Nervous system: lack of focus poor concentration forgetfulness jagged speech anxiety insomnia depression feeling wired at times Bowels: How are your bowel eliminations? How often? 3 times daily once per day skip days Amount normal too little too large Color brown black whitish Other lots of mucus lots of gas foul smell intestinal cramping international travel Consistency normal too hard very soft diarrhea alternating diarrhea/constipation Urination: How are your daily urinations? every 2 to 3 hours too frequent sense of urgency too small amount too large amount burning dribbling up at night several times Women only: pregnant breast feeding date of last period: menopause hysterectomy monthly periods regular (28 days) days of your menstrual flow have taken birth control medication bone loss/osteoporosis Symptoms associated with your period: cramping bloating feeling weak mood swings cravings heavy bleeding back pain headaches bright red blood dark clotty blood painful breasts painful menses Men only: decreased libido tire easily prostate trouble complications with heart high blood pressure irritability decrease in muscular strength depressive mood feeling burned out

5 Medications or supplements you are currently taking: List below your 4 main health concerns in order of importance: 1) 2) 3) 4) Describe any scars on your body and their causes. Please list any surgeries, operations, traumas, car accidents, etc. Check any areas that apply: Glasses/Contacts AIDS Arthritis Neck Pain Blood Pressure High Blood Pressure Low Skin Irritations Swollen Joints Epilepsy TMJ Dysfunction Poor Circulation Cold sores/herpes Asthma Claustrophobic Eczema or Psoriasis Hepatitis Contagious Disease (please explain): Are you currently under the care of a physician? Yes No If so, for what condition(s)? 635 Green Street, N.W. Gainesville, GA (678) (o) (678) (f)