Dr. Kateri Porto

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

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First & Last Name

Working EMAIL address (This is how we will communicate with you)

Re-enter your EMAIL address

Your Phone number (This is for our reference. We will not telephone you.)

What health concern would you like us to help you with?

Our available Office hours are: 9 am - 8 pm Monday, Tuesday, Thursday, & Saturday. Please choose a few dates and times that work best for you. We will do our best to accommodate your needs.

I understand that Garrett Ezell DC PC is in network with Blue Cross Blue Shield PPO, but not other insurances. If I have insurance that covers "Out of Network Providers" for Chiropractic Medicine, I can be provided with a coded receipt, called a "super-bill" so that I can submit a claim to my insurance provider on my own. 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 I am required to pay for those at the time they are rendered.

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Garrett Ezell DC PC is a Provider for Blue Cross Blue Shield Professional Network PPO & Blue Choice PPO. Are you a Member of BCBS PPO?

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I understand that the next 6 questions are for BCBS PPO Members. Members can find the first 3 answers on the left side of their insurance card. If I am not a member of this particular insurance I can leave these questions blank.

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1) What is your BCBS PPO Member Name? (as it reads on your insurance card)

2) What is your BCBS alphanumeric Member ID?

3) What is your BCBS Group No?

4) What is your date of birth? (mm/dd/yyyy) We need this to access your insurance benefits.

5) If applicable, what is the name of the "primary" member? (For example, if you share a plan through your spouse or employer)

6) If applicable, what is the birth date of the "primary" member? (We need this verify your policy)

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.

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I also understand that if I am accepted as a patient, I may need to discontinue care with other CAM 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.

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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.

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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 72 hrs either the doctors response was filtered into my "spam" messages or the email address I provided was incorrect. I will write the doctors again and provide a "working" email address.

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I understand that Dr. Porto and Dr. Ezell phone numbers are ONLY for use by CURRENT patients with "time sensitive" matters, and that all questions and comments should be relayed to these doctors at patient visits or via email.

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After clicking on the box stating "I am not a Robot", the screen will switch to one that says "Your form has been successfully submitted! Thank you!" If it does not switch right away you MUST "Click" the button that reads, "Click to Make Contact". If you do not see this please refresh your browser and try again--in this case you will have to fill in the answers again. The other option is to email us directly at kp1111ge@gmail.com. Please include the answers to the Contact form's questions.