Do Not Type In This Box

Client Full Legal Name:       Current Title:

Client Contact Information (Physical Address):

Client Contact Information (Electronic):

To maintain confidentiality, the email above is where medical information will be emailed; provide an email where others do not have access.

Here, specify the focus of my visit requesting. If left blank, these factors may not be considered for the findings:

SSN:   Client ID/Source (indicated on physician/hospital record):

Age/DOB:      Weight:      Height:   

Gender:    Race:        Blood Type:     Eye Color:    

Early Warning Signs (EWS)

Oxygen:         Temperature:    

Last Blood Pressure:     Level of Consciousness:  

Recent Blood Work From Primary MD (Results):

Recent Comprehensive Metabolic Blood Prick/Swab/Urine Analysis From ND (Results/NA):

Conventional Medications Current Intake (Reason/Dose/Frequency) Effect:


Medication Allergies:

Food Allergies:  
 
Complementary Remedies/Natural Supplements Current Intake (Reason/Dose/Frequency) Effect:

Medical History [indicate ICD-10 code (s) if known] [indicate if you have had a previous genetic testing and have a report]
 

Liver damage:    
Heart damage:
Cancer/Tumor: (Stage/Dimension):   

    Diagnostic Test: Mammogram/CAT/MRI/PET/Bone Density/X-ray/Ultrasound/Nuclear Scan (State/Date/Results):
   

    Cancer Treatments at/by MD:

Recreational Habits (Alcohol/Tobacco/Street Drugs & Frequency):

Food Consumption Preference: Vegetarian, Vegan, Semi-Vegetarian/Pescetarian, Omnivore (select one):  

Religion/Spiritual Beliefs:

Family Medical History:

Medical Physician (VA Provider)
Name: Address: Phone: Email: Do you wish for your screening/lab findings to be released to this Physician:

Medical Physician (private MD)
Name: Practice Name: Address: Phone: Email: Do you wish for your screening/lab findings to be released to this Physician:

Medical Physician (private OBGyn)
Name: Practice Name: Address: Phone: Email: Do you wish for your screening/lab findings to be released to this Physician:

Caregiver (Home-Based Family Caregiver)
Name: Address: (same as Client) Phone: Email: Do you wish for your screening/lab findings to be released to this Caregiver:

 Caregiver (Home-Based Agency Caregiver)
Caregiver Name: Licensed Agency Name: Agency Address: Caregiver Phone: Caregiver Email: Do you wish for your screening/lab findings to be released to this Caregiver:
 

For Service Professionals w/ Private Occupations: First, we should always thank service members for their service. Complete All that applies:

• Military Branch:    MOS (Title):
   
• Police Department:    Duty Hours:
   
• Fire Department:    Duty Hours:
   
• State Department:    Foreign Duty Post:
   
• Civilian Occupation:    Work Hours:

PSTD Origination (War Zone/Other):   Year PSTD Diagnosed By Licensed MD/Therapist: 
Other Trauma:   Year Diagnosed by a Licensed Psychiatrist/MD): 

Veteran Disability (w/Rating):   
VA Disability Claim:

Instructions: Type Your Explanations After Each Question. Do Not Remove the Text in the Textbox:

Health Coaching

How do you feel about: (a) The Self: (b) Your Contributions to the U.S. Military:

Symptom 1 ~ Physical (Describe~Location, Duration, Frequency):

Symptom 1(b) ~ For Women Only ~ Physical ~ Women Issues [state if pregnancy (trimester), do not have ovaries, etc] (Describe~Location, Duration, Frequency):

Symptom 2 ~ Mental (Describe~ Duration, Frequency):

Symptom 3 ~ Emotional (Describe~ Duration, Frequency):

Symptom 4 ~ Other (Describe~Location, Duration, Frequency):

Symptom 5 ~ Other (Describe~Location, Duration, Frequency):

Primary Private Insurance:   

Secondary Insurance (Medicare/Medicaid/VA):

Next of Kin Name/Phone Contact In Case of Emergency:

Date of Initial Appointment:

Client Electronic Signature (full name/last 4 of ssn) :

Caregiver Signature (only sign if Lab Client is unable to sign):
 

After pressing "Submit" print your confirmation page twice, one to mail/email via pdf to the Firm and one to maintain for your records.
Mail to: Brigette's Natural Healthcare Research and Laboratory, 105 Wilson Circle, Newnan, GA  30263 USA
 By pressing the submit button, I said name Client, agree to the terms indicated on the Client Application webpage (Brigette's Technology Consulting and Research Firm--Brigette's Natural Healthcare Research and Laboratory Division~hereby known as the "Firm"), understand that this natural support service does not diagnoses, treat, or alleviate diseases or the effects of diseases, and understand that waived lab kits will be used for this screening service for "medical neccessary" purposes and according to guidelines set forth by and authorized by the CDC (CLIA). I understand the kit and lab fees may not be covered by insurance companies, and that the said name Client is ultimately responsible for all payments. I also certify that all the information presented in this submission is true, and I consent to the use of the disclosure of this information submitted for natural healthcare lab and screening services provided by the Firm, and according with HIPAA laws. I acknowledge that the said name Client's email address provided is secure, and that the Firm cannot and will not be held liable for any breach in the email system or of the information or misinformation transmitted using this electronic platform. I further understand the Firm cannot or will not be held legally liable for any symptoms (prior, current, future) to include symptoms that have been indicated or omitted in this transmission associated with the condition or disease of which a licensed medical physican (MD) or another licensed healthcare professional has diagnosed for the said named Client. I further understand that the said Client is given Informed Consent to hold a telephone and/or teleconference communication for this screening process. This Service Agreement and any dispute there under shall be governed by Federal healthcare laws and regulations set forth by the U.S. Governement and the State of Georgia, USA. Any litagations and dispute will be held in Newnan, GA, USA.