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    New Patient forms

    We look forward to partnering up!

    Before we can get started, please download, complete, and return the four (4) Required Forms.

    We ask that forms are returned via email or fax
    at least 48 hours prior to the initial appointment.

    1. Health Questionnaire

    2. HIPPA Compliance

    3. Email Security Policy

    4. Financial Policy

    • Authorization to Release Medical Records (to Dr. Charny)

    • Authorization to Release Medical Records (from Dr. Charny)

    • Consent to Treatment of a Minor

    Clinical Forms

    • NTAF Questionnaire

    • Brain Localization

    • Diet log

    • Metabolic assessment form

    Have any questions?

    We are here to help!
    You can call or email with any questions.

  • Dysbiocide $35.50
  • Detoxification and Drainage Kit $72.00
  • Glutathione + Lemon Mint $50.00