Dr. Kateri Porto

I have read "Understanding the Healing Crisis", and I fully understand that holistic medicine works differently than conventional medicine.

Yes
No

Your FIRST & LAST NAME

Your EMAIL ADDRESS (This is how we will communicate with you. Please double check that it is correct.)

Your PHONE NUMBER (This is for our reference. We often do not have availability to telephone prospective patients, so please provide ALL the information we request on this secure form.)

Your MAILING ADDRESS: (This is for our reference. We will not send you flyers or junk mail.)

What HEALTH CONCERNS would you like us to help you with? (If you are writing on the behalf of your child please include their name and date of birth. If you are writing on behalf of an able adult or an almost adult teen, please provide their email address so we can copy them on any correspondence.)

Our OFFICE HOURS are: Monday: 9am-3pm, Tuesday: 1pm-7pm, Wednesday: 9am-4pm, Thursday: 9am-3pm, Friday: 1pm-7pm, and Saturday: 9am-7pm. Please choose a few dates and times that work best for you. We will do our best to accommodate.

FINANCIAL: I understand that Garrett Ezell DC PC is only in network with Blue Cross Blue Shield PPO, and not BCBS supplementary Medicare plans, nor any other insurance companies. If I have insurance that covers "Out of Network Providers", I can be provided with a coded receipt, called a "super-bill" so that I can submit a claim to my insurance on my own, or the doctors can submit that claim for me. I also, understand that if I do not have insurance, or I am in need of services that are not covered by my insurance, that it is my responsibility to pay for those at the time they are rendered.

Yes
No

INSURANCE: I am a BCBS PPO member.

Yes
No

INSURANCE: What is your BCBS alphanumeric Member ID? (If you are not a member you can leave this blank.)

INSURANCE: What is your BCBS Group No? (If you are not a member you can leave this blank.)

What is YOUR DATE of BIRTH? (mm/dd/yyyy) (We need this to access your insurance benefits.)

INSURANCE: If you are not the Primary BCBS Member, please provide the Primary Members Name and Date of Birth. Without this we cannot access your insurance benefits. (If you do not have BCBS PPO insurance you can leave this blank.)

RESPONSIBILITY: I understand that Dr. Porto and Dr. Ezell work together on each patient without exception. And that I am to take responsibility for my health by complying to at least 5 weeks of diet and lifestyle modification instead of solely relying on in office treatment alone. Diet modification includes that you will be required to consume healthy animal protein and essential fats which are derived from animal sources.

Yes
No

COMPLIANCE: I also understand that if I am accepted as a patient, I may need to discontinue care with other Complimentary Alternative Medicine practitioners or risk discharge for noncompliance with my personalized treatment plan. Going for a massage, adjustment, applying or smelling therapeutic oils that are not on my treatment plan could create adverse reactions, and delay my progress.

Yes
No

EXPECTATION: I understand that not all conditions are "curable" in 1 treatment visit. Some conditions are complex and chronic in nature, and may require months or even years to completely reverse.

Yes
No

COMMUNICATION: I understand that Dr. Porto and Dr. Ezell usually respond to messages within 24 hrs, and that if I have not received a response within 48-72 hrs either the doctors response was filtered into my "spam" messages, the email address I provided was incorrect, or I failed to check off the "I am human" box and follow the pop-up prompt before sending and the doctors never received my message.

Yes
No

CAPTCHA & CLICK HERE TO SEND: You must click on the box beside "I am human" before the "Click here to Send" button or the doctors will not receive your message. This is an important security feature. You may need to disable your pop-up blocker.