Nat Health Patient Form

Patient Intake Form

The following form patient intake form will take you through the steps we need to get you ready for your first visit with us.  There are 8 pages in all and if you should miss a required field it will take you to the area(s) you need to complete before moving on. Once we have your form we will be able to set you up for your first visit with us. 

If Patient is Under 18

Emergency Contact

Treatment Questions

Communication of Personal Health Information

Please indicate which methods are acceptable to use to communicate information regarding your treatment. The options you select grant Natural Health permission to communicate any and all information with you in this manner. This includes efforts made to collect payments, appointments, insurance information , health care information, balance forwards, etc. We may also contact you by text messages or emails using any email addresses and phone numbers you have provided to us.
Please include Relationship and Phone Number if not listed above.

Privacy Policy

I understand t as part of my treatment with Natural Health Sports Therapy that no personal and or health information may be left with anyone but the patient. I also understand that as part of Natural Health's treatment, payment, or health care operations it may become necessary to disclose my health information to another entity (my doctor, insurance company, etc.) and I consent release of appropriate information for these uses, including via fax.
I agree to your Policy

ORANGE COUNTY COSTA MESA

1784 NEWPORT BLVD.

COSTA MESA, CA 92627

Hours Of Operation:

Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday

 

7:00 AM – 5:00 PM
7:30 AM – 7:00 PM
7:00 AM – 5:00 PM
7:30 AM – 7:00 PM
7:00 AM – 4:00 PM
by appointment only
Closed