Nutritional Patient Questionnaire

First Name

Last Name

Date of Birth

Address

City

State

Zip Code

E-Mail (Required)

By documenting your email address on this page, you are agreeing that health information for yourself can be freely shared via email between yourself and the Take 2 Healthcare. While usually considered safe, email is not the most secure method of sharing personal information.

Primary Phone Number

Telephone: Work

Place of Employment

Occupation

Status

Number of Children

Spouse's Name

Spouse's Place of Employment

In case of emergency, who should we contact?

Emergency Contact Phone

Emergency Contact Relationship

How did you hear about our office?

We will provide a receipt for you to submit to your insurance. You are responsible for payment in full at the time of service. By signing below you are stating that you clearly understand that all services rendered at the Take 2 Healthcare are your responsibility and payment is expected at the time of service.

Date

Nutritional Informed Consent

According to the Federal Food, Drug, and Cosmetic Act, as amended, Section 201 (g) (1), the term "DRUG" is defined to mean:

"Articles intended for use in the Diagnosis, Cure, Mitigation,Treatment or Prevention of disease."

A Vitamin is not a drug,NEITHER is a Mineral, Trace Element, Amino Acid, Herb, or Homeopathic Remedy.

Although a Vitamin, a Mineral, Trace Element, Amino Acid, Herb or Homeopathic Remedy may have an effect on any disease process or symptoms, this does not mean that it can be misrepresented or be classified as a drug by anyone.

Therefore, please be advised that any suggested nutritional advice or dietary advice is not intended as a primary treatment and/or therapy for any disease or particular bodily symptom.

Nutritional counseling, vitamin recommendations, nutritional advice, and the adjunctive schedule of nutrition is provided solely to upgrade the quality of foods in the patient's diet in order to supply good nutrition supporting the physiological and biomechanical processes of the human body.

Nutritional advice and nutritional intake may also enhance the stabilization of chiropractic adjustments and treatment.

I have read and understand the above.

Insurance Billing

Dr. Van Merkle, Dr. Andrew Dyer, Dr. and Natalie Yahle, are out of network with all insurance companies. While we do not bill your insurance company for you, you are welcome to submit a claim on your own seeking reimbursement. Before you do, please consider the following...

1. If you file a claim with your insurance company, all diagnosis codes and test results will go on file with your insurance company. This can be used to determine future premium costs for you and your family.

2. If your diagnosis includes a hereditary disease like high blood pressure, it will not only be seen on your health records, but also the records for your children and grandchildren and will be used to determine their coverage availability and premium costs.

3. Insurance companies are quick to raise premiums or drop coverage entirely when customers file too many claims, or just one of the wrong kind of claim (like nutritional treatment rather than the medical drug-fix it norm).

4. Your insurance carrier is responsible only for paying benefits covered under your policy and will deny anything they deem "medically unnecessary or experimental". Nutritional services frequently fall under this category and therefore are not covered which means you are supplying them with diagnosis codes, test results, etc (which they can use against you) yet you see no financial benefit.

5. Rescission -if you have a serious illness, insurance companies will search your file to obtain medical records from the last several years and if they find any inconsistency in your application, your policy is rescinded so they can avoid paying for costly treatments or medication. Any information you share with them could be used against you.

6. Preapproval - if you call your insurance company to find out if certain services are covered, it is a warning sign to your provider that bills are coming which may spark a rescission search on your account.

Van D. Merkle, DC, CCN, DACBN, DABCI
Tracey C. Barry, MS
Andrew Dyer, DC, DABCA
Natalie Yahle, DC

5777 Far Hill Ave
Dayton, Ohio 45429
Phone:(937) 433-3241
Fax:(937) 496-5468
Email: mail@take2healthcare.com