Copyright (C) 2008 Pangea Natural Health, LLC
new patient forms
ADULTS/TEENAGERS: Please print and fill out both forms.
CHILD: Parents, please print and fill out both forms. NOTE: If patient is of the age to fill out their own form, please use the adult form above.
Notice of Privacy Practices: Please read this notice prior to signing the receipt of privacy policy section on the New Patient Information Form.
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Welcome to Pangea Natural Health! Thank you for making an appointment. I look forward to meeting you. Please print and fill out the following forms (adult or pediatric health profile, new patient info form). It is very important that Dr. Wiegand receives a copy of your health profile prior to your first visit. You can fax it to 208.354.9578, mail it to PO Box 579 if appt is at least 2 days away (for local folks), scan it and email to chante@pangeanaturalhealth.com, or drop it off at the office at 65 South Main Street, Suite 6 (slide it under the door if I am unavailable). If unable, please bring to your first appointment, along with copies of any recent lab reports and bottles of supplements you are currently taking.
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New Patient Information Form
Adult Health Profile Form
New Patient Information Form
Pediatric Health Profile Form