Forms and Handouts

Distance Patient Consulting:

Becoming a long‐distance patient does not detract from the quality of care. If all of the bases are covered, in the beginning (labs, consultation, history, forms…), than the quality of treatment and potential outcome are virtually identical to a patient being seen in my office.

Distance Patient Information, Forms and Fees

If for some reason you can’t open the forms on the distance patient application, they are all above in the “New Patient Forms” section above with the red asterisk next to them. You will still need to print out the “Distance Patient Application”, fill it out and send it in with all the other applicable forms and tests. Thank you.

In Office – New Patients:

1. Please print and fill-out all (6) forms under the heading, “New Patient Forms.”

2. THIS IS VERY IMPORTANT: All of your forms MUST be filled out, COMPLETELY and returned within 3 working days of your new patient appointment. Please include all pertinent reports and/or laboratory tests with your paperwork. A delay in me receiving, beforehand, your forms/tests will most likely take need time away from our consultation/examination. If you arrive without your forms completely filled out your appointment WILL be rescheduled and you may be subject to a missed appointment fee. Please see form #1 for more details.

“I can only help you to the degree you help me. I will do my part, as a doctor, to the best of my ability, each and every time you come into my office. Please do your part by being on-time and with all of your forms filled out. Thank you in advance, Dr. Ettinger

New Patient Forms:

  1. *Fee Schedule 2016
  2. *Coach Health Consultant Status Form
  3. *Metabolic Assessment Form
  4. *Three Day Nutritional Diary (print out just one page if your appointment is within the next 48 hours). Include supplements and medications.
  5. *Bio-Health Diagnostics Survey (men and women, fill out all sections).

Additional Forms: (fill out only if requested by Dr. Ettinger)

  • Medical Records Release Form
  • Neuro-Transmitter Assessment Form
  • Credit Card Authorization Form

Office Handouts:

  • Dr. Ettinger’s Paleo-Work-Book-1-31-12-update-2-2-16 (routinely updated)   
  • Gluten Free and Gluten Containing Grains
  • Lectins in Edible Foods & ABO Blood Type Reactions
  • HPA-HPT Axis Chart
  • Chronic Stress Response Chart
  • Steroidal Hormone Pathway Chart
  • Physiological Aspects of Cortisol and DHEA
  • High Doses of Antioxidants Including Vitamin C Do Not Decrease the Efficacy of Chemotherapy