Living Springs Natural Health (LSNH) & Living Springs Health & Wellness (LSHW), PLLC are members under the:

TURTLE ISLAND PROVIDER NETWORK Licensed & Registered by: Tribal Health Programs & Clinics

A Private Tribal Membership Facility NOT OPEN TO THE PUBLIC

NEW CLIENT FORM FOR USE AT LIVING SPRINGS

Name: Enter Your Full Name	DOB: Select Your Birth Date.	Date: Select Today’s Date.

Address: Enter Your Street Address City: City State: State Zip: Zip Code

Phone: __Phone #__ Email: ____Email Address____ Gender: Select Your Gender

Occupation: Enter Your Occupation Marital Status: Select Status # of children: Select #

Name and Phone number of Emergency Contact: __________Click or tap here to enter text_____________

How did you hear about us? Click or tap here to enter text.

Personal History

Please list any allergies (including medications): Click or tap here to enter text.

Please list any significant illnesses/surgeries: Click or tap here to enter text.

Please list medications you take on a regular basis: Click or tap here to enter text.

Please list vitamins/supplements you take on a regular basis: Click or tap here to enter text.

Please select the box if you have any of the following:

Pacemaker	☐	Dark Urine	☐

Heparin Allergy	☐	Abdominal/back pain	☐

Receiving Chemo or Radiation	☐	Fatigue	☐

Anemia	☐	G6PD	☐

Fever	☐	Are you pregnant?	☐

Do you smoke?	☐	If so, how much?	☐

Do you drink alcohol?	☐	If so, what kind & how much?	☐

Do you take illegal drugs?	☐	If so, what kind & how often?	☐

Click or tap here to enter text.

What is the primary reason that you visited our office today? Click or tap here to enter text.

Please list other Providers that you are seeing: Click or tap here to enter text.

***Please note… We do not file insurance at this office & will not provide codes. The alternative therapies/suggestions we provide are not intended to diagnose, treat, cure or prevent any disease ***

☐ I understand, agree & provide my consent that the submission of this form electronically requires the use of a digital signature. By signing, I agree that my digital signature on this form has the same legal affect as my manual signature (in accordance with the ESIGN Act).

E-Sign Your Name Here

Patient Signature

Once you have finished filling out the highlighted sections above, save file to your computer, then submit the form(s) by uploading the file at: https://www.livingspringsnaturalhealth.com/forms