Expanding the Practice of Integrative Medicine
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INTEGRATIVE WELLNESS ASSOCIATES
STEPHEN PANEBIANCO, MD
AMY PANEBIANCO, BA
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Tucson, AZ
520-820-5568
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New Client Interest Form
First Name:
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Do you have any specific symptoms or established
illness that you are seeking consultation on?
By clicking the submit button, I accept Dr. Panebianco's
Consultation Payment Policy as described.
I further acknowledge that Dr. Panebianco encourages me to maintain a relationship with a primary health care provider or other health care professionals as needed. If urgent or emergent needs arise, I will contact my on-call physician or proceed to the local Emergency Department.
Copyright © 2006, Integrative Wellness Associates, All Rights Reserved.
How did you learn about our consultation services?
If yes, what health issue are you seeking consultation about?
Do you have a diagnosis? If so, please state:
What are your symptoms?
How long have you had the symptoms or health issue?
What other health care professionals or healing arts practitioners are a part of your health care team?
Do you have a primary care physician?
Do you have any particular health goals that you would like to work towards?
Do you have a particular health area that you would like more information about such as optimal nutrition, supplementation, Clinical Hypnosis, MBSR-Mindfulness Based Stress Reduction, or referrals to other healing arts practitioners?
This form is a request for Dr. Panebianco to review your interests and
needs to help determine if they can best be supported through the
consultation services of Integrative Wellness Associates.
Which consultation service are you interested in?
What type of health care coverage do you have?
