Vitalized Performance Group
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Patient Forms
If possible, please print and complete each page of the form then fax, email, or bring it with you to your first appointment. Online Intake is available, click here
Patient Forms
If possible, please print and complete each page of the form then fax, email, or bring it with you to your first appointment. Online Intake is available, click here
Fax: 860-430-2843
Email: [email protected]
Snail mail or drop in our mailbox:
212 New London Turnpike, Suite D Glastonbury, CT 06033
[email protected] is a HIPAA COMPLIANT 3RD PARTY ENCRYPTED EMAIL: PLEASE USE THIS EMAIL FOR ALL IMPORTANT AND CONFIDENTIAL EMAILS. ALL PROVIDERS HAVE ACCESS TO THIS EMAIL. We understand that many households use shared e-mail addresses. You give us permission to send emails where others can potentially access the information. With today’s advances in technology and the busy lifestyles that people lead, email is often preferred over other forms of communication when it comes to confirming appointments or sending lab test results. However, patients/clients should be aware that even despite extensive efforts on the part of the healthcare provider to protect sensitive information, no email is 100% safe.
Please bring a valid photo ID to your first appointment.
Colon Hydrotherapy:
1. First-time clients should first print and complete the patient intake form. You can return completed forms by using the methods described to the left.
2. Our naturopathic doctor will review your intake form* and make sure receiving colonics is safe for you. This is an annual requirement. You might receive a call to clarify your information if such clarification is necessary.
3. You will then receive a call or email from our office to confirm that you are approved and to schedule your first appointment.
If you choose an outside physician to fill out your approval "prescription" you still must fully complete our intake forms.
Click here for VPG Wave's Blank Prescription Form Here
OR
A valid doctor prescription pad must include "approval for a full series of colon hydrotherapy services" "use as needed." (they may add, any additional comments if they choose.)
*VERY IMPORTANT, THE FIRST NOTICE FROM MINDBODY, FOR YOUR 1st APPOINTMENT WITH THE ND, IS NOT AN APPOINTMENT YOU NEED TO COME IN FOR! THIS IS JUST AN APPOINTMENT THE ND WILL HAVE TO REVIEW YOUR INTAKE. PLEASE DO NOT COME IN IF YOU GET AN APPOINTMENT REMINDER FROM MINDBODY OR VITALIZED PERFORMANCE GROUP FOR NATUROPATHIC MEDICINE: ND COLONIC REVIEW. *
Colon Hydrotherapy:
1. First-time clients should first print and complete the patient intake form. You can return completed forms by using the methods described to the left.
2. Our naturopathic doctor will review your intake form* and make sure receiving colonics is safe for you. This is an annual requirement. You might receive a call to clarify your information if such clarification is necessary.
3. You will then receive a call or email from our office to confirm that you are approved and to schedule your first appointment.
If you choose an outside physician to fill out your approval "prescription" you still must fully complete our intake forms.
Click here for VPG Wave's Blank Prescription Form Here
OR
A valid doctor prescription pad must include "approval for a full series of colon hydrotherapy services" "use as needed." (they may add, any additional comments if they choose.)
*VERY IMPORTANT, THE FIRST NOTICE FROM MINDBODY, FOR YOUR 1st APPOINTMENT WITH THE ND, IS NOT AN APPOINTMENT YOU NEED TO COME IN FOR! THIS IS JUST AN APPOINTMENT THE ND WILL HAVE TO REVIEW YOUR INTAKE. PLEASE DO NOT COME IN IF YOU GET AN APPOINTMENT REMINDER FROM MINDBODY OR VITALIZED PERFORMANCE GROUP FOR NATUROPATHIC MEDICINE: ND COLONIC REVIEW. *
Intake forms are necessary for:
1. Acupuncture
2. Cupping/Gua Sha/Tuina/
3. GAINSWave/Shockwave treatments
4. Colon Hyrdo-Therapy
5. Medical Consultations with a Naturopathic Physician or an APRN
6. EFT Emotional Freedom Technique, or Nutritional Health Coaching
7. Fascia Blasting Treatment
For all other services mentioned below, a simple one or two page intake form will be provided prior 1st treatment in the office
1. Bio- Mat
2. Far Infrared Sauna-Dome
3. Ionic Foot Bath
Please make sure to bring in your photo Id to your first appointment and hand it to your provider.
Intake forms are necessary for:
1. Acupuncture
2. Cupping/Gua Sha/Tuina/
3. GAINSWave/Shockwave treatments
4. Colon Hyrdo-Therapy
5. Medical Consultations with a Naturopathic Physician or an APRN
6. EFT Emotional Freedom Technique, or Nutritional Health Coaching
7. Fascia Blasting Treatment
For all other services mentioned below, a simple one or two page intake form will be provided prior 1st treatment in the office
1. Bio- Mat
2. Far Infrared Sauna-Dome
3. Ionic Foot Bath
Please make sure to bring in your photo Id to your first appointment and hand it to your provider.