New Patient Forms

Let’s get started

Preparing for your first visit

  1. Call our office (561) 842-7422 and we will advise you as to which forms to fill out.

  2. Fill out the relevant forms below and bring in prior to your initial consultation. We require at least the New Patient Form for Men or the New Patient Form for Women.

  3. Please also email us copies of any lab work completed in the past year including recent laboratory results, and anything you deem important. You can email them to us but please also print and bring to your consultation. Need to fax records? Here’s our number: 561-842-0848

  4. Schedule an initial 60-90 minute consultation to meet with us at our office Healthy Living & Longevity Medical Center (8295 N Military Trl suite k, Palm Beach Gardens, FL 33410).

Once we’ve met with you, patients regularly schedule follow up consultations as needed. It is our privilege to partner with you on your journey to wellness.

 

Have you considered Peptide Therapies? Click HERE to read more about the benefits and solutions we offer! Want to print and read later? Click HERE.

Men

Our new patient form for Men is 24 pages long and allows us to know the extent and severity of your symptoms. We can then monitor change improvements over time. We are attuned to common issues such as low testosterone, high cholesterol, heart disease, high blood pressure, erectile dysfunction, and more.

PLEASE FILL OUT THIS FORM

Women

Our new patient form for Women is 28 pages long and allows us to know the severity and extent of your symptoms. We can then monitor change improvements over time. We commonly explore issues such as PMS, Menopause, Perimenopause, sleeplessness, low libido, depression, low energy, weight gain, memory issues, preconception issues, and more.

PLEASE FILL OUT THIS FORM

 

Adrenal Fatigue

This questionnaire can be helpful if you have been under chronic stress. This form allows us to answer the question, “Do I have adrenal fatigue?” If you score high enough we can go forward and test you.

PLEASE FILL OUT THIS FORM

Defining Your Deficiencies

Sometimes amino acid therapies are useful. They help make neurotransmitters. Answer the questions in terms of how you feel right now; it doesn’t matter how long you’ve been experiencing these symptoms, or even if they occurred today for the first time.

PLEASE FILL OUT THIS FORM

 

Sexual Enhancement/ Oxytocin

This assessment gathers your information to assess Oxytocin deficiency. Oxytocin is known as the “love hormone”, but helps with chronic stress and much more.

PLEASE FILL OUT THIS FORM

Toxic Heavy Metals and Mold

Are you exposed to environmental toxins like mold, or toxic heavy metals? We have a list of common symptoms patients have when exposed to poisonous metals or mold mycotoxins. For mold patients, please fill out page four and the first section of page five and bring those pages into the office. For patients with toxic heavy metals exposure, please fill out the entire form.

PLEASE FILL OUT THIS FORM

 

Notice of Office Policies and Procedures

Unfortunately many insurance companies do not pay for preventive procedures or reversal of disease. This means that Dr. Bieley is a fee for service physician and does not accept insurance. Dr. Bieley has opted out of Medicare. A receipt shall be provided to you upon request with diagnosis and treatment codes which may be submitted to your insurance company. Lab testing is usually covered by Medicare and many insurance policies (consult your policy).