The online form below will take about 15 minutes to complete. This maximizes your time together on your first visit with Tony.

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Chadwell Method Intake Form

(month/date/year)

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I am 18 years old or older. If not, I have provided written permission from my parents or legal guardian to participate in treatment.

I understand that my success is directly related to my readiness to change and my level of commitment to my personal growth.

I understand that payment is expected at the time of service. I may choose to submit a receipt of this visit to my insurance company for reimbursement but that it is my responsibility to secure whatever reimbursement, if any, according to the policies and procedures of my insurance carrier.

I understand that Anthony Chadwell is not a Physician and does not Diagnose or Treat Disease.

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Metabolic Assessment Form

PART 1
Please list your 5 major health concerns in order of importance

PART II

Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Category I

Category II

Category III

Category IV

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Category V

Category VI

Category VII

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Category VIII

Category IX

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Category X

Category XI

Category XII

Category XII

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Category XIV

Category XV

Category XVI

Category XVII

Category XVIII (Males Only)

Category XIX (Males Only)

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Category XX (Menstruating Females Only)

Category XXI (Menstruating Females Only)

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PART III

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PART IV

Please list any natural supplements you currently take and for what conditions

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Permission and Authorization Form G2G Health Systems Inc. and Chadwell Center for Health

PLEASE READ BEFORE SIGNING:
I specifically authorize the natural health practitioners at Chadwell Center for Health. to perform a nutritional health analysis and to develop a natural, complimentary health improvement program for me. My program may include dietary guidelines, nutritional supplements, etc. in order to assist me in improving my health, and not for the treatment, or “cure” of any disease.


I understand that the analysis used are a safe and non-invasive natural method of analyzing the body’s physical and nutritional needs, and that deficiencies or imbalances in these areas could cause or contribute to various health problems.



I understand that the analysis used is not a method for “diagnosing” or “treating” any disease, including conditions of cancer, AIDS, infections, or other medical conditions, and that these are not being tested for or treated.



No promise or guarantee has been made regarding the results of any analysis performed or any natural health, nutritional or dietary programs recommended. I understand that the analysis performed is a means by which to determine possible nutritional imbalances, so that safe,natural programs can be developed for the purpose of bringing about a more optimal state of health.



Furthermore, I understand that I am fully responsible for all aspects of my own healthcare, and will not hold Chadwell Center for Health, its employees, or agents, liable for any actions I take based on the information provided.



I have read and understand the above.



This permission form applies to all visits and consultations.

(If minor, signature of parent or guardian)