Downloadable Forms

New Patient Intake Form Packet

In order to minimize time spent in the waiting room filling out forms and to allow Dr. Weyrich to review your case prior to meeting with you, all new patients making an appointment to see Dr. Weyrich should download, print, fill out, and fax back to Dr. Weyrich at (888) 391-0414 the applicable PDF files listed below prior to your first visit (right click button to Download):

You must first decide whether you want Dr. Weyrich to do:

• Physical medicine (spinal manipulation, McManus spinal traction [Dr. Gear-style "manipulative surgery"], ultrasound, massage, G5, diathermy, mechanical intermittent traction, far-IR sauna, SCENAR, therapeutic exercise, biofeedback, neurofeedback, etc). These treatments must be administered in person at 4 Health and Wellness.
• Internal medicine (hormone balancing, anti-aging, nutrition, herbs, acupuncture, etc). Before treatment can begin, Dr. Weyrich must do a physical examination in person at 4 Health and Wellness, but much of the time, telemedicine consultations may suffice.
• Or both physical and internal medicine.

Choose zero or one of the following:

•  V   
  Intake for physical medicine ONLY
•  V   
  Intake for BOTH physical medicine and internal medicine

Choose zero or one of the following:

•  V   
  Intake for internal medicine (Female)
•  V   
  Intake for internal medicine (Male)

Choose zero or more of the following:

•  V   
  Required if you need to send records from other doctors to Dr. Weyrich
•  V   
  Required if you are of Medicare age
•  V   
  Optional of you want to do "telemedicine" with Dr. Weyrich

Please fill-out and bring all original pages with you to your appointment.

If you do not understand any part of the any of the forms, leave that part blank and put a question mark in the left margin of the form for that question.