In preparation for your appointment, please complete all forms prior to arriving at the clinic. The more thoroughly you complete the forms, the more efficient our first visit will be and the better care we will be able to provide to you.

  • Download the Consent for Treatment, complete it on your computer, print, and sign. 

  • If we need to request your records and/or labs from another provider, download the Authorization to Disclose, complete it on your computer, print, and sign. You will need to complete one for each facility at which you see providers. If you see several providers at one facility, only one Authorization to Disclose would be necessary.

  • Please review the Notice of Privacy Practices

  • Download the Intake Form and save to your computer. Choose the longer, Chronic Conditions form if you have three or more chronic conditions, otherwise choose the Short FormComplete the form on your computer. Ideally, bring it to the clinic on a jump/flash drive. Otherwise print it and bring it to the clinic with you for your first visit. Do not bring in hand written intake forms. 

  • If you are being evaluated for Lyme disease, please download Dr. Horowitz's MSIDS Questionaire, complete it on your computer, either save it on a jump/flash drive or print it, and bring it to the clinic with you for your first visit. We do need to see the form. Knowing the total score is not sufficient.

  • If you are being evaluated for Lyme disease, please download and print Dr. Crista's Mold Questionnaire. You will need to complete this one by hand.

If you are seeing us for HBOT Only:

  • Please review the Notice of Privacy Practices

  • Download, print, and complete the Intake Form and the Medical History forms. 

  • Download, print, and sign the appropriate Consent and Waiver form. If the patient is under the age of 18, choose the "Child" form. The parent or guardian must sign. 

  • Read Introduction to HBOT. This document explains what to expect during a treatment, but also how to prepare for the treatment, in particular that no scented personal care products are to be worn before your treatment and the type of clothing to be worn in the chamber. Failure to follow these guidelines may result in postponement of your treatment. 

DO NOT COMPLETE ANY FORMS ON-LINE. DOWNLOAD THEM TO YOUR COMPUTER AND COMPLETE THEM ONCE THEY ARE SAVED TO YOUR COMPUTER. 

These forms will become part of your confidential medical record and will only be shared as outlined in the Notice of Privacy Practices. 

All Patients

Notice of Privacy Practices

All Patients (excluding HBOT)

Authorization to Disclose

Short Form

Intake Form - Short Form

Chronic Illness or Medical Mysteries

MSIDS 

Questionnaire

HBOT Treatments

Consent and Waiver - Adult

Consent and Waiver - Child

Introduction to HBOT

Telemedicine Consent Form

Everhope Clinic PLLC

 
Billings, MT  59105
406-899-HOPE (4673)
406-200-9595 Fax
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All visits by appointment only. Evenings and weekend appointments available. 

© 2019 Everhope Clinic, PLLC