Registration Forms

Welcome to new patient and client registration! Please download and complete the intake forms and bring them with you to your first appointment. 

IMPORTANT INFORMATION TO READ ABOUT REGISTRATION:

• Dr. Garner is not a participating Medicare provider. If you would like to be seen for wellness or maintenance programming ONLY and you are on Medicare, then Dr. G can discuss the parameters for being seen.
• Patient Privacy Disclosure Statement: In filling out the patient registration, I understand that EudeMOMia will maintain my privacy to the highest standards and may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment.

New Patient & Client Registration 

You CANNOT BE SEEN until the following forms are completed:

• Informed Consent & Policy Agreement
• Telehealth Consent
• New Patient Registration
  
• OPTIONAL FORMS
  • IF you believe that dry needling may be right for you, please read and complete this consent form: Dry Needling Consent
  • For those with longstanding or persistent pain, please complete this online quiz and bring a copy of the results to your first appointment. Trouble with the online version? Print it out and take it: SF-36 Intake Form.

Medical Record Release Form

If you need to share your medical records from Dr. Garner’s office with another provider, this form must be completed. 

• Medical Record Release Form

Women’s Health

Please complete these forms if you have any hip, pelvic, or back pain or pain related to sex or are postpartum (no matter how many years it has been since your last birth). If you are a dancer or gymnast, please also complete these forms. 

• Women’s Health Patient History Intake Form
• Bladder Diary Instructions
• Bladder Diary
• Dancer and Women’s Health Inventory
• Edinburgh Postpartum Depression Inventory

Neck and/or Back Pain

Please complete if you have neck or back pain.

• Oswestry Back Pain Inventory
• Neck Disability Inventory

For Ayurvedic Consults Only

If any of these forms are needed Dr. Garner will have you complete them at a later date.

• Constitutional Analysis 
• Twenty Attributes Self-Test 
• Ayurvedic Daily Routine