New Patient Intake Form

I consent to evaluation, examination, and treatment by Dr. Stallone and the staff at Arizona Integrative Medical Center. I understand that naturopathic medicine includes various modalities such as nutritional counseling, herbal medicine, homeopathy, physical medicine, IV therapy, and prescription medications when appropriate.

I understand that payment is due at the time of service. Arizona Integrative Medical Center is an out-of-network provider for most insurance plans. I will be provided with a superbill to submit to my insurance company for potential reimbursement. I understand that the practice is not responsible for determining my insurance benefits.

I understand that I must provide at least 24 hours notice to cancel or reschedule an appointment. Failure to provide adequate notice may result in a cancellation fee. No-shows may be charged the full appointment fee.

I acknowledge that I have been informed of Arizona Integrative Medical Center's privacy practices and my rights under HIPAA. I understand how my protected health information may be used and disclosed. I have the right to request a copy of the full Notice of Privacy Practices. View Privacy Policy

I certify that the information I have provided on this form is accurate and complete to the best of my knowledge. I understand that providing inaccurate information may affect my care and treatment.