Forms
Intake Forms
Forms needed prior to your first visit
The patient intake form is used to gather contact details along with your current and past health information. This provides us with a comprehensive overview and serves as a starting point for understanding your health care needs.
Supplimental intake forms
A women’s fertility history form is used to gather detailed information about your reproductive health. It helps healthcare providers understand factors that may impact fertility, such as menstrual history, past pregnancies, contraceptive use, hormonal treatments, and any previous fertility concerns or medical conditions. This form serves as a foundation for personalized care, fertility assessments, and treatment planning.
The pediatric intake form is used to gather current and past health information for your child. This provides us with a comprehensive overview and serves as a starting point for understanding their health care needs.
The Mona Lisa Touch and ThermiVA Complementary Consult Intake is used to gather information from patients interested in learning about the Mona Lisa Touch treatment. It collects details about your medical history, symptoms, and concerns to help the provider determine if this laser therapy for vaginal and pelvic health is a suitable option for you. It also ensures the consultation is personalized to your specific needs.
Patients coming in for IV Therapy need to complete the IV Therapy Intake prior to your first IV visit and we will have you sign an IV Consent Form upon arrival.
Treatment Information
Pre-procedure information for patients having the Mona Lisa Touch procedure.
Post-procedure information for patients having the Mona Lisa Touch procedure.
Administrative forms
The insurance verification form is the form you will you use to make sure you obtain needed information when you call your provider to verify your insurance coverage (e.g. providers and services that are covered in and out of network, deductibles, number of visit limitations, etc.).
This form is for requesting Amber Wellness Group to send records to another provider/facility.
The form is to allow Amber Wellness Group to disclose protected health information to to a guardian, spouse or family member.
Policies
The Good Faith estimate and Fee schedule reviews the codes we commonly bill with both insurance pricing and self-pay pricing for those not using insurance.