Health Forms

Cancellation Policy

We respectfully ask clients to cancel scheduled appointments at least 24 business-hours in advance. If you do not cancel within the 24 hour time-frame, you will be charged the full appointment fee.

For first-time appointments, we require at least 48 business-hours notice for an appointment cancellation. If you do not cancel within the 48-hour time-frame, you will lose the deposit amount.

Health Forms

Please click on each practitioner’s name to access and download their forms. Some forms are fillable after download. Please do not fill out the forms until after download, as information entered in your web browser will be lost when you go to download or print.

Jennifer Salos, MS, CNC

Send completed form by email to Jennifer or fax to 410-757-6742 – before your appointment.

Client Orientation Form (before first appointment only)

Health History (before first appointment only)

Health Profile Questionnaire (before each appointment)

Pediatric Health History (before first appointment only – 12 years and under)

Saliva Evaluation Form (before each saliva appointment)

Carol Heckman, RN, CNHP, MH, CNC

Send completed form by email to Carol or fax to 410-757-6742 – before your appointment.

Client Orientation Form (before first appointment only)

Health History (before first appointment only)

Health Survey (before each appointment)

Pediatric Health History (before each appointment)

Hormone Health Survey (before each appointment)

Cathy Logan, CHC, COT, CECP

Send completed form by email to Cathy or fax to 410-757-6742 – before your appointment.

Foot Detox Service Waiver (before first appointment only)

Glynda Cullen, LMT, LE

Send completed form by email to Glynda or fax to 410-757-6742 – before your appointment.

Skincare Questionnaire (before first appointment only)

Foot Detox Service Waiver (before first appointment only)

Lisa Manning, CST, CHt

Send completed form by email to Lisa or fax to 410-757-6742 – before your appointment.

Craniosacral Intake Form (before first appointment only)

Minor Release Form (before first appointment only)

Hypnosis Intake Form (before first appointment only)

Hypnosis Services Disclosure (before first appointment only)

 

Kyle D. McIntyre, PT, DPT, CFMT

Coming soon…

Carrie Singer, RN, MAc, LAc

Coming soon…

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The programs and services offered by Chesapeake Holistic Health are not substitutes for medical advice or treatment prescribed by your physician. You are urged to seek the advice of a physician before beginning any nutrition or supplementation program or protocol. Our programs, services, and information should not be construed as medical advice, and Chesapeake Holistic Health disclaims any liability from and in connection with this information. As with any exercise or nutritional program, if at any point during the program you begin to have any physical discomfort, you should stop immediately and consult a licensed health practitioner. Individual results may vary, and past performance is not an accurate predictor of future results. No statements or claims made by employees or representatives of Chesapeake Holistic Health have been evaluated by the United States Food and Drug Administration.