The UltraWellness Center > Current Patients > Patient Checklist

Patient Checklist

Did you remember to...?

  • Read all of the practice documents.
  • Obtain your medical records and/or test results from previously seen physicians and have them sent to The UltraWellness Center at 45 Walker Street, Lenox MA 01240, arriving at least 7 days prior to your appointment date.
  • Provide your preferred shipping/mailing address; if listing a P.O. Box please indicate a street address for receiving packages, UPS or FED EX.
  • Provide us with your pharmacy name, address, phone and FAX number.

Fill out and/or sign the following forms:

  • Important Patient Information
  • Authorization for Release of Medical Information
  • Informed Consent Regarding Email or the Internet Use Of Protected Personal Information
  • Research Consent Form
  • Notice of Medicare Denial
  • General Information
  • Medical Questionnaire
  • 3-Day Diet Diary
  • MSQ - Medical Symptom/Toxicity Questionnaire
  • SF-36 (Quality of Life Assessment)