Appointment Request - Modern Wellness Clinic

Please use the online form.
* = Required Information

Today's Date
(Auto Filled) Today's Date
(Auto Filled) / MM / DD YYYY
Personal Info
Patient Name Patient Name * First Last
Phone Number Phone Number * - ### - ### ####
Email *
Home Address Home Address *
Street Address
Address Line 2 City State / Province / Region Postal / Zip Code Country
Employee Name
If you chose Employee (Referred By)
Please select the services needed
(Select ALL that apply) *

Please select the services needed
(Select ALL that apply) Primary Care / Specialty Mental Health Hormone & Sexual Health Weight Loss IV Therapy Aesthetics Restorative Medicine Functional Medicine Other Medical Services Other Medical Services
Have you been seen at Modern Wellness Clinic before? *

Have you been seen at Modern Wellness Clinic before? New patient Established patient
Do you have health insurance? *

Do you have health insurance? Yes No
Attach a picture of your Drivers License / ID Card:

Attach Files
Attach a picture of your Health Insurance Card:
(Front Of Card)

Attach Files
Attach a picture of your Health Insurance Card:
(Back Of Card)

Attach Files
Would you like to attach your medical records? *

Would you like to attach your medical records? Yes No
Modern Wellness Clinic
1. Authorization to Release Records

I hereby authorize the use or disclosure of my health information as described below.
Records to be released from:

Records to be released from: Myself (personal medical records) Previous Primary Care Provider Specialist(s) Other (specify) Other (specify)
Name/Facility to release records:
Address of releasing provider (if known): Address of releasing provider (if known):
Street Address
Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone of releasing provider (if known): Phone of releasing provider (if known): - ### - ### ####
Fax of releasing provider (if known): Fax of releasing provider (if known): - ### - ### ####
2. Records to be Disclosed
I authorize the release of:

I authorize the release of: Complete Medical Records Last 2 Years of Medical Records Lab and Imaging Reports Immunization Records Other (specify) Other (specify)
3. Records to be Sent To:

Modern Wellness Clinic
5375 S Fort Apache Rd Suite 102 & 103, Las Vegas, NV 89148

(702) 463-9159
4. Purpose of Disclosure

4. Purpose of Disclosure Continuity of Care (transfer of care to Modern Wellness Clinic) Personal Use Other Other
5. Expiration & Revocation

This authorization will expire 12 months from the date signed unless otherwise specified:

I understand that I may revoke this authorization at any time in writing, except to the extent that records have already been released.
6. Patient Rights

I understand that:
• Refusal to sign this authorization will not affect my right to receive treatment.
• Once released, records may no longer be protected under HIPAA if received by a non-covered entity.
• I am entitled to a copy of this authorization.
Has any or your personal information changed?
(Insurance, Address, Phone number, Pharmacy, Allergies, ) *

Has any or your personal information changed?
(Insurance, Address, Phone number, Pharmacy, Allergies, ) Yes No
What personal information has changed?
(Select ALL that apply)

What personal information has changed?
(Select ALL that apply) New Insurance Address Phone number Pharmacy New Allergies
Attach a picture of your NEW Health Insurance Card:
(Front Of Card)

Attach Files
Attach a picture of your NEW Health Insurance Card:
(Back Of Card)

Attach Files
Attach a file for follow up appointment.
(Optional)

Attach Files
Attach a file for Medical Records.
(Optional)

Attach Files
New Address New Address *
Street Address
Address Line 2 City State / Province / Region Postal / Zip Code Country
NEW Phone Number NEW Phone Number * - ### - ### ####
NEW Pharmacy Name *
New Allergies *
Print Name & Relationship (if not patient)
Comments / Notes
(Optional)
By checking this box, I confirm that I am requesting to be contacted by Modern Wellness Clinic. I agree to the Terms of Service and Privacy Policy, and I consent to receive SMS messages at the number I provided, including replies to my inquiry, appointment reminders, special offers, and marketing communications. Message frequency may vary. Message and data rates may apply. Reply STOP to unsubscribe. *

By checking this box, I confirm that I am requesting to be contacted by Modern Wellness Clinic. I agree to the Terms of Service and Privacy Policy, and I consent to receive SMS messages at the number I provided, including replies to my inquiry, appointment reminders, special offers, and marketing communications. Message frequency may vary. Message and data rates may apply. Reply STOP to unsubscribe. Yes
Signature of Patient/Legal Representative: *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Appointment Request - Modern Wellness Clinic

Appointment Request - Modern Wellness Clinic

Personal Info

Modern Wellness Clinic

1. Authorization to Release Records I hereby authorize the use or disclosure of my health information as described below.

2. Records to be Disclosed

3. Records to be Sent To: Modern Wellness Clinic 5375 S Fort Apache Rd Suite 102 & 103, Las Vegas, NV 89148 (702) 463-9159

5. Expiration & Revocation This authorization will expire 12 months from the date signed unless otherwise specified: I understand that I may revoke this authorization at any time in writing, except to the extent that records have already been released.

6. Patient Rights I understand that: • Refusal to sign this authorization will not affect my right to receive treatment. • Once released, records may no longer be protected under HIPAA if received by a non-covered entity. • I am entitled to a copy of this authorization.

1. Authorization to Release Records

I hereby authorize the use or disclosure of my health information as described below.

3. Records to be Sent To:

Modern Wellness Clinic
5375 S Fort Apache Rd Suite 102 & 103, Las Vegas, NV 89148

(702) 463-9159

5. Expiration & Revocation

This authorization will expire 12 months from the date signed unless otherwise specified:

I understand that I may revoke this authorization at any time in writing, except to the extent that records have already been released.

6. Patient Rights

I understand that:
• Refusal to sign this authorization will not affect my right to receive treatment.
• Once released, records may no longer be protected under HIPAA if received by a non-covered entity.
• I am entitled to a copy of this authorization.