New Patient Intake Form New Patient Intake Form Step 1 of 13 7% Dear New Patient, Welcome, and thank you for choosing Dr. Celaya as one of your health care providers. OUR CONSULTATION PROCESS: STEP 1: During your initial consultation, Dr. Celaya will review your health history and make recommendations for lab tests that are appropriate for your specific health issues. STEP 2: Once you have completed your lab tests, Dr. Celaya will explain the meaning of your test results to you in a follow-up consultation. He will create an individualized therapeutic program for you including diet changes, nutritional supplements, and exercise, lifestyle, and stress management advice. STEP 3: Subsequent consults are scheduled to monitor your progress. Dr. Celaya will also design an on-going wellness program to be reviewed and updated with our staff at no charge every six months. We invite you to contact us via email or phone should you have any questions during the course of your treatment. We look forward to assisting you in achieving your current wellness goals, and to guiding you in maintaining wellness throughout your life. You will automatically be enrolled in our newsletter to provide you free cutting-edge health information to support you on your health journey. If you wish to not receive the newsletter, feel free and unsubscribe. In Health, Dr. Celaya and the Wellness Team! Please take your time filling this form out. We suggest that you take it slowly, and occasionally use the "save and continue later" option at the bottom. This will save your work in case of a glitch or a spotty internet connection. Date MM slash DD slash YYYY How did you hear about us?Name* First Last Birthdate MM slash DD slash YYYY GenderMaleFemalePrefer Not to AnswerHeightWeight NowWhat is your weight now?Ideal WeightWhat is the weight of which you think you are at your best?Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail* Enter Email Confirm Email Civil StatusSingleMarriedDivorcedSeperatedWidowNumber of Children123456789101112131415EMPLOYMENTEducationHigh SchoolAssociate DegreeBachelor's DegreeGraduate or Professional DegreeSome CollegeOtherPrefer Not to AnswerOccupationEmployed Full-TimeEmployed Part-TimeSelf-employedNot employed but looking for workNot employed and not looking for workHomemakerRetiredStudentPrefer Not to AnswerJob TypeFull-TimePart-TimePer DiemEmployeeTemporaryContractInternSeasonalJob IndustryAccounting/FinanceAdvertising/Public RelationsAerospace/AviationArts/Entertainment/PublishingAutomotiveBanking/MortgageBusiness DevelopmentBusiness OpportunityClerical/AdministrativeConstruction/FacilitiesConsumer GoodsCustomer ServiceEducation/TrainingEnergy/UtilitiesEngineeringGovernment/MilitaryGreenHealthcareHospitality/TravelHuman ResourcesInstallation/MaintenanceInsuranceInternetJob Search AidsLaw Enforcement/SecurityLegalManagement/ExecutiveManufacturing/OperationsMarketingNon-Profit/VolunteerPharmaceutical/BiotechProfessional ServicesQA/Quality ControlReal EstateRestaurant/Food ServiceRetailSalesScience/ResearchSkilled LaborTechnologyTelecommunicationsTransportation/LogisticsOtherYears EmployedYears EmployedLess than a month1-6 months1-3 yearsOver 3 yearsOver 5 yearsOver 10 yearsOver 20 years30 years or moreSpouseSpouse's NameSpouse's Phone Number What are you top 5-10 major symptoms not diagnosed? Please list in order of importance, 1 being most important 10 being least important.*What are your overall health goals once your major complaints are resolved?*What year do you recall your first health symptoms occurring, and what was it?*What else was happening in your life around the time your symptoms started?Please list any previous diagnosis you have.*Please list out any medications, nutritional supplements or vitamins you're currently taking?In the past, have you used antibiotics , if so how long and frequent?In the past, have you used birth control pills , if so how long? Do you presently have any of these G.I. or digestive symptoms? (check all that apply) Bloating Constipation Diarrhea GERD Heartburn Unexplained weight change Previous gut infection Nauseousness Stomach gurgling Travel outside of the USA Anemia (Iron or B12) Do you presently have any of these respiratory symptoms? (check all that apply) Allergies Asthma Dyspnea (Air Hunger) Sleep Apnea Congested Sinuses Do you presently have any of these ears, eyes, nose and throat symptoms? (check all that apply) Sinus congestion Sinus polyps Excessive earwax Reoccurring ear infection Tinnitus or ear ringing Difficulty swallowing Swollen throat Vision issues Hearing loss Do you presently have any of these endocrine or hormone related symptoms? (check all that apply) Adrenal dysfunction Fibroids Endometriosis Ovarian cysts Low libido PMS (Premenstrual Symptoms) Decrease in morning erections Hypothyroidism Hyperthyroidism Pituitary or hypothalamus related problem Amenorrhea or no period Anemia (Iron or B12) Do you presently have any of these cardiovascular related symptoms? (check all that apply) High blood pressure Abnormal lipid levels Low blood pressure Dizzy when standing up fast Cold hand and or cold feet History of heart attack Do you presently have any of these reproductive related symptoms? (check all that apply) Miscarriage Abortion Low sperm count Infertility STD (Sexually Transmitted Disease) Do you presently have any of these urinary related symptoms? (check all that apply) Urinary tract infection Bacterial vaginosis Yeast infection Bladder infection Kidney infection Do you presently have any of these musculo-skeletal related symptoms? (check all that apply) Back pain Neck pain Shoulder pain Headaches Hip pain Knee or leg pain Foot pain Arthritis Osteoporosis Do you presently have any of these skin, hair and nail related symptoms? (check all that apply) Rashes Eczema Acne Psoriasis Dry skin Itchy skin Hives Hair loss Outer 1/3rd of eyebrows thinning Abnormal hair growth (darker, thicker more coarse hair) Vertical ridging on nails White spots on nails Weaker more brittle nails Fungal nails with slight yellowish hue Dandruff How much sleep do you get each night on average?What time do you go to sleep and wake up? How many times do you wake up during the night?Have you ever had a root canal or mercury silver fillings? Please list out when and how many you currently have.Do you have any food allergies, sensitivities or restrictions?Do you smoke, drink alcohol or use recreational drugs? How often?How often do you drink caffeinated beverages?Please list out your typical breakfast, lunch and dinner below. Please also list out the time of day you consume these meals too.Are there any specific diets you have followed (Atkins, Paleo, Autoimmune, SCD, Vegetarian etc)? If so how long?What diet made you feel the best?Are there foods that you eat on a daily basis, almost daily basis?Are there any disease that run in your family especially autoimmune disease like Parkinson, Celiac, Hashimoto's etc.Are you happy in your life right now? Explain.What are your main sources of stress?How do you deal with your stress?Do you have a history of an eating disorder: Anorexia, bulimia or very low calorie dieting? No Yes How often do you exercise and what kind of exercise do you do?If you do not currently exercise, what types of exercise have you enjoyed doing in the past? Do you have any history of infections or tick bites?Please list surgeries and or hospitalizations starting with most recent.Briefly describe where you have lived since childhood.What is your heritage? (Irish, German, Spanish, etc.) Metabolic AssessmentPlease select the appropriate number on all questions below, 0 as the least or never to 3 as the most or always.Section 1Feeling that bowels do not empty completely.0123Lower abdominal pain relieved by passing stool or gas.0123Alternating constipation and diarrhea0123Diarrhea0123Constipation0123Hard, dry, or small stool0123Coated tongue or “fuzzy” tongue0123Large amount of foul-smelling gas0123More than 3 bowel movements daily0123Use laxatives frequently0123Section 2Excessive belching, burping or bloating0123Gas immediately following a meal0123Offensive breath0123Difficult bowel movements0123Sense of fullness during and after meals0123Difficulty digesting fruits and vegetables undigested food found in stools0123Section 3Stomach pain, burning, or aching 1-4 hours after eating0123Use of antacids0123Feeling hungry 1 or 2 hours after eating0123Heartburn - lying down or bending forward0123Temporary relief by using antacids, food, milk, or carbonated beverages0123Digestive problems subside with rest and relaxation0123Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine0123Section 4Roughage and fiber cause constipation0123Indigestion and fullness last 2-4 hours after eating0123Discomfort on left side under rib cage0123Excessive passage of gas0123Nausea and/or vomiting0123Undigested, foul smelling, mucous and/or greasy stool0123Frequent urination0123Difficulty losing weight0123Section 5Greasy or high-fat foods cause distress0123Lower bowel gas and/or bloating several hours after eating0123Bitter metallic taste in mouth, especially in the morning0123Unexplained itchy skin0123Yellowish cast to eyes0123Stool color alternates - clay to normal brown color0123Dry flaky skin/hair0123Gallbladder removedyesnoSection 6Crave sweets during the day0123Irritable if meals are missed0123Depend upon coffee to get going0123Lightheaded if meals are missed0123Eating relieves fatigue0123Feel shaky or jittery or have tremors0123Agitated or easily upset0123Poor memory0123Blurred vision0123Section 7Fatigue after meals0123Crave sweets during the day0123Eating sweets does not relieve craving for sugar0123Must have sweets after meals0123Waist girth is equal or larger than hip girth0123Frequent urination0123Increased thirst and appetite0123Difficulty losing weight0123Section 8Cannot stay asleep0123Crave salt0123Slow starter in the morning0123Afternoon fatigue0123Dizziness when standing up quickly0123Afternoon headaches0123Headaches with exertion or stress0123Weak nails0123Section 9Cannot fall asleep0123Perspire easily0123Under a high amount of stress0123Weight gain when under stress0123Wake up tired even after 6 or more hours of sleep0123Excessive perspiration or perspiration with little or no activity0123Section 10Tired/sluggish0123Feel cold―hands, feet, all over0123Require excessive amounts of sleep to function properly0123Increase in weight even with low-calorie diet0123Gain weight easily0123Difficult, infrequent bowel movements0123Depression/lack of motivation0123Morning headaches that wear off as the day progresses0123Outer third of eyebrow thinning0123Thinning of hair on scalp, face, or genitals, or excessive hair loss0123Dryness of skin and/or scalp0123Mental sluggishness0123Section 11Heart palpitations0123Inward trembling0123Increased pulse even at rest0123Nervous and emotional0123Insomnia0123Night sweats0123Difficulty gaining weight0123Section 12Diminished sex drive0123Menstrual disorder or lack of menstruation0123Increased ability to eat sugar without symptoms0123Section 13Increased sex drive0123Tolerance to sugars reduced0123"Splitting" type headaches0123Section 14 (Males only)Urination difficulty or dribbling0123Frequent urination0123Pain inside legs or heels0123Feeling of incomplete bowel evacuation0123Leg nervousness at night0123Section 15 (Males only)Decrease in libido0123Decrease in spontaneous morning erections0123Decrease in fullness of erections0123Decrease in maintaining morning erections0123Spells of mental fatigue0123Inability to concentrate0123Episodes of depression0123Muscle soreness0123Decrease in physical stamina0123Unexplained weight gain0123Increased fat distribution around chest and hips0123Sweating attacks0123More emotional than in the past0123Section 16 (Menstruating females only)Are you perimenopausalnoyesAlternating menstrual cycle lengthsnoyesExtended menstrual cycle, greater than 32 daysnoyesShortened menses, less than every 24 daysnoyesPain and cramping during periods0123Scanty blood flow0123Heavy blood flow0123Breast pain and swelling during menses0123Pelvic pain during menses0123Irritable and depressed during menses0123Acne breakouts0123Facial hair growth0123Hair loss/thining0123Section 17 (Menopausal females only)How many years have you been menopausal0123456789101112131415161718192020+Since menopause, do you ever have uterine bleedingnoyesHot flashes0123Mental fogginess0123Mental fogginess0123Disinterest in sex0123Mood swings0123Depression0123Painful intercourse0123Shrinking breasts0123Facial hair growth0123Acne0123Increased vaginal pain, dryness or itching0123 How many alcoholic beverages do you consume per week?12345678910111213141515+How many caffeinated beverages do you consume per day?1234567891010+How many times do you eat out per week?12345678910111213141515+How many times per week do you eat fish?1234567891010+List the 3 worst foods you eat during a typical weekList the 3 healthiest foods you eat during a typical weekHow many times a week do you eat raw nuts or seeds?12345678910111213141515+How many times do you work out per week?12345678910111213141515+What type of exercise?Do you smoke?noyesHow many cigarettes per day?123456789101112131415161718192020+Rate your stress level on a scale of 1-10 during the average week12345678910Lab reports Drop files here or Select files Max. file size: 128 MB. If you have had lab work within the last year, we want to see it. In addition, if you have had lab work even before that which is pertinent to Dr. Celaya understanding your health issues, make sure you send that to us also. You can send multiple files at one time with this option. Lab reports Drop files here or Select files Max. file size: 128 MB. If you have had lab work within the last year, we want to see it. In addition, if you have had lab work even before that which is pertinent to Dr. Celaya understanding your health issues, make sure you send that to us also. You can send multiple files at one time with this option. Lab reports Drop files here or Select files Max. file size: 128 MB. If you have had lab work within the last year, we want to see it. In addition, if you have had lab work even before that which is pertinent to Dr. Celaya understanding your health issues, make sure you send that to us also. You can send multiple files at one time with this option. Fee Schedule Phone or Skype Consultation Phone - New Patient Consult $299 New patient 45-60 minute consultation. Phone - Follow Up Consultation $150 For existing patients only. Functional medicine 30-45 minute consult. 1-2 labs test may be reviewed during this time. Phone - Brief Consultation $100 For existing patients only. Brief 15-30 minute consult. This consult is designed for questions on diet, lifestyle and the supplement program. 1 lab test may be reviewed if time permits. Phone - Troubleshoot Consultation $150 For existing patients only. A quick 15-minute consultation to troubleshoot any issues with your functional medicine program. Labs are not reviewed in this type of appointment. Phone - Comprehensive Consult $200 For existing patients only. Functional medicine 60-minute consult. During the consult diet, lifestyle, supplement program, and 2-3 labs test may be reviewed during this time. Phone - Nutrition Follow Up Consultation $100 Nutrition follow-up consultation. Office Consultation Office - New Patient Consult $399 New patient 45-60 minute consultation. Office - Follow Up Consultation $150 For existing patients only. Functional medicine 30-45 minute consult. 1-2 labs test may be reviewed during this time. Office - Brief Consultation $100 For existing patients only. Brief 15-30 minute consult. This consult is designed for questions on diet, lifestyle and the supplement program. 1 lab test may be reviewed if time permits. Office - Troubleshoot Consultation $150 For existing patients only. A quick 15-minute consultation to troubleshoot any issues with your functional medicine program. Labs are not reviewed in this type of appointment. Office - Comprehensive Consult $200 For existing patients only. Functional medicine 60-minute consult. During the consult diet, lifestyle, supplement program, and 2-3 labs test may be reviewed during this time. Office - Nutrition Follow Up Consultation $100 Nutrition follow-up consultation. After Hours Consultation New Patient Consult After Hours $399 This is an after hour appointment for new patients to see Dr. Justin. New patient 45-60 minute consultation. If no times are available online in the next 1-2 weeks, please email the office as other times are set aside. Trouble Shoot Consult After Hours $150 This is an after hour appointment for existing patients that need to see the Doctor sooner. Existing patient 15-30 minute consultation. If no times are available online in the next 1-2 weeks, please email the office as other times may be set aside. Initial here to confirm fee schedule*Appointments Follow-up consults may be scheduled in 15, 30, 45, or 60-minute blocks of time. We encourage you to book your appointments 4 weeks in advance. As a courtesy to you, our office will email you 3-7 days in advance to remind you of your appointment. Lab Tests The results of your lab test(s) will be sent to Dr. Celaya 2 to 4 weeks after mailing your specimens to the lab. Dr. Celaya will evaluate the results. After your evaluation, you will be contacted to schedule a follow-up appointment. Certain blood work can be billed to the patient's insurance, depending upon the type and your deductible. When insurance is not available, cash discount options can be used to purchase blood work. The patient is responsible for any lab work their insurance does not cover. Cancellations If you are unable to keep your scheduled appointment, you must notify our office a minimum of 48 hours before your scheduled time or you may be charged for that appointment. Dr. Celaya has patients waiting to be seen, and a missed appointment takes time away from someone else. If The Doctor Is Running Late You must be available for the entire time of the consult. The Doctor may be running late with his previous patient, you will be charged a missed consult fee equal to the value of the consult if you are not available.Initial here to confirm cancellation policy*Super-Bills All receipts given at check out contain cpt codes and IC10 codes that can be submitted to your insurance company for reimbursement. The easiest way to do this is by calling the customer service number on the back of the insurance card to receive instructions regarding the submission of your claim. The Doctor is not responsible for any insurance claims that are not reimbursed. If there are any changes to a super-bill that need to be made, it is the responsibility of the patient to find out from their insurance what needs to be amended. The office will make adjustments to the super-bill at $5 fee per receipt. Any in depth paperwork that requires that Doctor to fill out will be charged to the patient at the doctors hourly rate.Initial here to confirm super bill policy*Returned Products PRE-APPROVAL IS REQUIRED ON ALL RETURNS! Supplements (unopened and non-refrigerated items) may be returned with a 15% restocking fee of the purchase price for store credit. No supplement returns will be accepted after 30 days on all regularly stocked items. No supplement returns will be accepted after 30 days. Special orders and refrigerated products are non-returnable. Prepaid tests can be returned for credit within 1 month of purchase. All ingredients for Dr. C's supplements can be found in the store as well. It's the patient's responsibility make sure there are no specific allergens in the supplements before they are shipped, the best time to address this is during the supplement program design. If products are sent and allergies are found after the fact, the above return policy applies. Important Notes Dr. Celaya is not a medical doctor; he does not service medical emergencies. If you have a medical emergency, you must contact your primary care physician or dial 911! Please contact the office if you are not clear on any of our policies or procedures. Dr. Celaya is not providing you Chiropractic treatment. Dr. Celaya does not treat or diagnose any disease. Dr. Celaya's work is to help support physical and chemical stress imbalances, with the goal of promoting wellness. Communication Outside of Scheduled Consultation Many people now use email as a primary way to communicate with others. We appreciate that email can be a great way to ask a quick question or clarify something from your last visit or share with us how you are doing. Yes or no questions are best with email correspondence. Questions that don't involve a back on forth dialogue that can be answered in 1-2 sentences are also acceptable. We have found through experience, however, that email is often not the best way to deal with more treatment-oriented questions and decisions such as questions regarding your medical issues, changes in your symptoms, or complex requests. Instead, in these cases please schedule an appointment so your doctor will have time set aside to directly hear and address your concerns. If there is not time available on the calendar for a troubleshoot consult, please email and call the office so we can find a time to squeeze you in. If you have sent us an email and have not heard back from us after several days, please follow up with a phone call. Dr. Celaya is not a medical doctor, for any medical emergencies please call 911. If you are in need of refills on prescription medication, please see the original prescribing physician. Initial here to confirm communication and shipping policy*Clinic Policies and Procedures. A full list of policies and procedures can be found at https://drcelaya.wpmudev.host/FAQ (click here). All policies are subject to change. Please refer back to the website to stay up to date on any policy changes.I, (please print name here)*I have read and understood Dr. Celaya's Policies and Procedures.Date* MM slash DD slash YYYY Signature*Electronic Signatures Are Legally Binding Please complete this form if you would like us to share information about your progress with another person. Authorization to Release Medical Information To: Dr. Gregory A. Celaya 1325 E. Thousand Oaks Blvd., #104 Thousand Oaks, Ca 91362 I, (Please provide full name) request the following informationUntitled Test results Reports History Progress reports Accident information Injury information Diagnosis Illness OthersTo be released toAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Extended menstrual cycle, greater than 32 days No Yes FaxFor the purpose of: (Specify)SignedDate MM slash DD slash YYYY Person signing is the Patient Spouse Gardian Parent Credit Card Payment Authorization Form Sign and complete this form to authorize Dr. Celaya to bill my credit, debit, flex or HSA card listed below. Please complete the information below: I, (Full name) authorize Dr. Greg Celaya to charge my credit card as listed below. Please attach a copy of your insurance card front and back if Dr. Celaya has requested it. 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CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Shipping Address (If different than billing address) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican 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agreement that has been signed and dated or card holder/patient has submitted to our office a written request to revoke the card usage (stop billing credit card in writing signed and dated). Patient's account is paid in full. NumberEmailThis field is for validation purposes and should be left unchanged.
