Into Well Being, PC

Noel John M. Carrasco, M.D., FAAP

Pat Murphy Carrasco, BSN, MFA, CMHT

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New Client Interest Form

This form is a request for Dr. Carrasco to review your situation to help determine if your needs can be supported through the consultatioon services of Into Wellbeing Pc.

First Name:
Last Name:
State: Zip Code:
Best Phone #:
Gender: Age:
How did you learn about our consultation services?
Which consultation service are you interested in?
Do you have any specific symptoms or established illness that you are seeking consultation on?
If yes, what health issue are you seeking consultation about?
Do you have a diagnosis ? If so, please state:
What are your symptoms?
How long have you had the symptoms or health issue?
What other health care professionals or healing arts practitioners are a part of your health care team?
Do you have a primary care physician?
Do you have any particular health goals that you would like to work towards?
Do you have a particular health area that you would like more information about such as optimal nutrition, supplementation, Clinical Hypnosis, Stress Reduction, or referrals to other healing arts practitioners?

By clicking the submit button, I accept Dr.Carrasco's Consultation Payment Policy as described. I further acknowledge that Dr. Carrasco encourages me to maintain a relationship with a primary health care provider or other health care professionals as needed. If urgent or emergent needs arise, I will contact my on-call physician or proceed to the local Emergency Department.

Consultation Payment Policy

1. Due to the time and information intensive nature of Dr. Carrasco's services, he does not accept insurance, Medicare, or Medicaid and payment is due in full at the time of service.

2. Dr. Carrasco accepts cash, credit, or debit cards required at the time of service. He does not bill.

3. Patients will receive a coded receipt for each visit that can be submitted to their insurance company for possible reimbursement. Any insurance issue that may arise is between the patient and their insurance company.

CANCELLATIONS: If you need to cancel your appointment please contact Integrative Wellness Associates at least a week in advance. Except for extenuating circumstances, Patients will be charged the full consultation fee for same day cancellations or "no show" appointments.




" Natural Forces Within Us Are The True Healers Of Disease "

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Disclaimer: The information provided on Into Wellbeing PC Online is for educational purposes only and IS NOT intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek professional medical advice from your physician or other qualified healthcare provider with any questions you may have regarding a medical condition.