This form will time-out after an extended period of time. Please dedicate the time to finish this form when you decide to start it.
The more information IHS has for your file, the better.
At IHS we get to the root cause of illnesses!
Do you have an alternate address for Summer/Winter seasons?
Please understand that Integrated Health Solutions, LLC communicates extensively through email. Keep in mind that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information you include in an email can be intercepted and read by other parties besides the person to whom it is addressed.
Be sure that the email address you are providing is one you check regularly.
Mark clientservices@ihsvt.com and quickbooks@notification.intuit.com as "Safe Senders". You will receive office documentation and correspondance, recommended supplement schedules, as well as account invoices or statements to the email address provided.
When was your cancer diagnosed?
Have you had surgery as a result of your cancer diagnosis?
Have you had a stem cell transplant?
Have you had seizures as a result from cancer?
Did you have seizures prior to your cancer diagnosis?
How many months have you been experiencing this?
Do you have other health issues/concerns that you would like Dr. Debbie to address?
Typically, Integrated Health Solutions, LLC likes to inform patients that for every 12 Months that one has a specific health issue, it could take up to 6 Months (if not longer) to start making significant progress against the said health issue. The body does not like change.
If you have multiple health issues currently, it could take a considerable amount of time to balance your body to achieve proper function. Please stay patient, and continue to Pray.
Can you recall the last time you really felt well?
Previous lab results, bloodwork, CT scans, MRI's... etc... are helpful to have in your file. Please scan/email to clientservices@ihsvt.com, fax (1-802-433-4260), or upload the documents here.
If you are unable to upload a list, please provide a list of current medications, supplements, OTC, etc... that you are taking.
It is our belief that genetics play a role in health.
Dr. Debbie will gladly profile out your genes, and provide you with health implications as well as recommended supplements which will help bypass specific gene defects.
If Yes... How many a day?
Do you have any restrictions on your diet?
If Yes, how many times do you wake up each night?
Are you often tired or fatigued?
Have you ever experienced depression / anxiety?
If Yes, have you taken medication(s) for depression / anxiety?
If yes, are you currently taking medication(s) for depression / anxiety?
To your knowledge, do you have any issues with blood pressure?
If Yes, have you taken medication(s) for blood pressure?
If yes, are you currently taking medication(s) for your blood pressure?
To your knowledge, do you have any issues with your cholesterol?
If Yes, have you taken medication(s) for cholesterol?
If yes, are you currently taking medication(s) for your cholesterol?
If Yes, where are they typically located (on/in your head)?
Rate each of the following symptoms based on your typical health profile for the last 2 weeks.
Select ALL that apply based on your typical health profile for the last 2 weeks.
Integrated Health Solutions, LLC recognizes that is can be difficult to notify our office with regular health updates, however, we rely heavily on them to give you the best quality care possible.
Our office staff tries their best to reach out to our patients regularly via email or phone. Please keep in mind that our patient load is quite large, so if you don't hear from us, it's not because you're not on our hearts. You are welcome to email or call our office at any time.
I understand and accept that I may be added to an online mailing list to receive office updates. I understand that I can unsubscribe from this mailing list at any time.
Please keep in mind that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information you include in an email can be intercepted and read by other parties besides the person to whom it is addressed. By signing below, I am giving my consent to communicate via email.
Our bio-feedback schedule is important for us to keep, so that we can stay focused on your health. The scan is our biggest tool to really inform Dr. Debbie about what is going on within. More often than not, we are questioned about how the scan works. It is difficult for most people to comprehend, however, the bio-feedback machine works in the realm of quantum entanglement (quantum physics).
I understand that I need to notify Integrated Health Solutions, LLC about how I am doing on my recommended protocol, regularly. I also understand that Dr. Debbie prefers to have an update prior to doing follow-up bio-feedback scans.
I know that Integrated Health Solutions, LLC cares about my health, and I can reach out to them via email or phone at any time.
Integrated Health Solutions, LLC is committed to providing you with high quality health care and to forming a relationship with you that is built on trust. This means respecting the privacy and confidentiality of your medical information. Any violation of confidentiality or the failure of an employee to protect your information from accidental or unauthorized access will not be tolerated. Corrective action will be taken and may result in the employee being terminated.
We will not allow others outside of Integrated Health Solutions, LLC to access your medical information unless we have the appropriate authorization to do so, or are required to do so by law. In most circumstances we will request your authorization to release personal health information. There are certain circumstances under which we may use or disclose identifiable health information about you without your authorization.
We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. Any specific written authorization you provide may be revoked at any time by writing to us at the address provided at the end of this notice. We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include your medical information.
Our policies may change at any time and without notice. Before we make any significant changes, we will notify our clients in a Newsletter. You can request a copy of the change(s) at that time.
I understand that Integrated Health Solutions, LLC is committed to keeping my healthcare information confidential, unless they are required to release it by law.
Integrated Health Solutions, LLC does NOT confer authority to practice medicine or to undertake the diagnosis, prevention, treatment, or cure of any disease, pain, deformity, injury, or physical or mental condition and specifically does not authorize any person other than one who is licensed health practitioner to state that any product might cure any disease, disorder, or condition.
Dr. Debbie Alsheimer consults and gives recommendations based on her knowledge of genetics, functional medicine, Chinese medicine, and bio-feedback technology. She works with her patients to develop function and balance within the body by detecting and correcting deficiencies and stresses.
I agree not to hold Dr. Debbie, her staff, and Integrated Health Solutions, LLC liable for consequences that may result from nutritional recommendations, supplementation, or bio-feedback treatments administered from this office.
I authorize Dr. Debbie Alsheimer to assist me in my healthcare endeavors. This may include, but is not limited to the use of bio-feedback scanning which uses long-distance technology (quantum entanglement), and/or the use of dietary supplementation.
I authorize Integrated Health Solutions, LLC to use my provided healthcare information, as well as information derived from this office to create a clinical case study, if desired.
Integrated Health Solutions, LLC does not accept insurances. All services must be paid for prior to, or at the time of service. All products must be paid for prior to the order being processed.
I understand that Integrated Health Solutions, LLC does not accept insurance, and that I am legally responsible for all charges associated with services provided.
I understand that Integrated Health Solutions, LLC will not send me products until the invoice is paid in full.
I agree to pay in-full for any products or services rendered by Integrated Health Solutions, LLC.
I understand that a payment not received within 15 days of the invoice being sent will be subject to a late payment penalty.
If I choose to provide Integrated Health Solutions, LLC with a CC to hold on file, I authorize them to run the card after a service has been rendered. They are to send me an invoice showing the paid status.
If I do not choose to provide Integrated Health Solutions, LLC with a CC to hold on file, I will make a timely payment through the quickbooks online invoice.
In the event of non-payment, I understand non-payment can be reported to credit reporting agencies and I agree to pay all reasonable costs of collection, including attorney's fees.
Refunds and/or credits will be applied to the patient's account upon receipt of the returned product(s). Product must be received in non-damaged condition.
There are no refunds for services rendered at any time. Service costs are non-refundable.
I am solely responsible for the decision to see Dr. Debra Alsheimer (Dr. Debbie) for Alternative Medicine care. My choice has been voluntary and I understand that I may terminate my treatment at any time. I recognize that some recommendations may not prove to be successful, and that it may take a significant amount of time to restore function in my body. I understand that by not following the recommended supplement schedule provided by Integrated Health Solutions, LLC, I may not see optimal results. I agree to participate in an active manner, to monitor my progress, and report any concerns to Dr. Debbie Alsheimer or her staff.
I also understand that any significant symptoms should be reported to my primary doctor or oncologist. It is also recommended that I discuss the use of any nutritional supplements with my doctor before implementing.
I fully understand and have read all the above legal documentation. By signing below, I accept all terms and conditions set forth by Integrated Health Solutions, LLC in regards to becoming a patient of theirs.
By signing and/or printing above, I am committing to becoming a new patient of Integrated Health Solutions, LLC.
I understand that once my paperwork is received, Integrated Health Solutions, LLC will get me on Dr. Debbie's schedule for an initial workup, only after I have paid my new patient fee.
We are so pleased to be working for you to help you achieve better health!
By submitting this form I am commiting to becoming a patient of Integrated Health Solutions, LLC.
I understand that I will not be placed on Dr. Debbie's schedule for an initial workup scan until my new patient fee has been paid.