Registration Form


Please fill out this form and we will get in touch with you shortly.
  • Date Format: MM slash DD slash YYYY
  • Please enter a 9 digit Social Security Number
  • Accepted file types: jpg, gif.
    Please upload a picture (headshot) of yourself or if you are the parent of a minor child either a picture of them or of the two (three) of you; so that we have a face to go along with the information you have given and so that you "appear" for us when we open your chart. Thanks.
  • If you are the patient, write in "self"; however, if you are the parent, sibling, custodian, child of the patient then input that information.
  • Use short form answers if possible.
  • Date Format: MM slash DD slash YYYY
    You musk click yes to become a patient.
    You must click yes to become a patient.
    I understand that the clinic is not “in-network” with any insurance companies and that the office operates as a “fee-for-service” office and that all services must be paid for at the time of the visit. I understand that I will be paying for “contact” with the doctor whether by email, phone or in-person; irregardless of whether my insurance offers reimbursement for this type of contact (charge for “non-local” contact will be at the clinic's discretion and will be charged at prevailing rates; however, in most cases this will not apply for urgent phone contact that lasts less than five minutes). I agree to allow Vitality Health & Wellness to charge my credit card for any outstanding balances that may occur from time to time.
    I understand that the office has a strictly enforced 24-hour cancellation policy and does not include weekends or holidays (i.e. an appointment scheduled for Monday morning at 10 am must be canceled by 10 am on Friday morning in order to avoid a cancellation charge). Cancellation fees will be based upon the amount of time that is scheduled for the office visit. The office will attempt to contact you as a courtesy prior to your scheduled appointment time as a reminder. Please be aware that when you reschedule your appointment, there will be a charge for that new appointment and the missed / cancellation within 24 hours fee does not get applied to the next appointment.
  • Please type in your name as a digital signature accepting our policies and the accuracy of the information provided above