Questionnaires
Start the Registration Process Here – If you haven’t already signed in to HINT (This is a two part process. You will self sign up for Hint through this link. A member of our staff will then invite you to Ultralight where you will fill out the required Medical Forms).
Once you have filled out the medical forms in Ultralight, as well as the necessary forms below, please give our office a call for scheduling. 319-471-4727
New Medical and Coaching Patients (required for scheduling)
New Patient Intake Contracts – Required
Forms Not Required for Scheduling
Established Patient Medical & Coaching Program Application
NOTE: COMPLETING THE ABOVE FORM DOES NOT GUARANTEE ACCEPTANCE INTO OUR DISCOUNTED MONTHLY PROGRAMS. AFTER SUBMISSION, YOUR APPLICATION WILL BE REVIEWED, AND YOU WILL BE NOTIFIED WITHIN 1 WEEK WHETHER IT IS ACCEPTED OR NOT. ALL ACCEPTED APPLICATIONS WILL GO ON A WAITING LIST FOR ROLLING ADMISSION TO DR. JULIA BUCHKINA’S AND TAMMY RICH’S MONTHLY SUPPORT PROGRAMS. IF YOU ARE NOT ACCEPTED, YOU MAY STILL CONTINUE TO SCHEDULE VISITS WITH DR. JULIA AND TAMMY AT “PAY AS YOU GO” PRICING, SUBJECT TO AVAILABILITY IN THEIR SCHEDULES
Medicare Private Contract for Age 65 and Over
Incapacitated Patient Access Agreement
Authorization to Disclose/Obtain Protected Health Information (fill this out for each facility, family member or friend you would like to share personal medical information with)
New Patient Program PAUSE Agreement (Only for current 3 or 6 month program patients)
Healing Room Clients Only
Healing Room Policies and Procedures Agreement