Health Assessment Questionnaire -- FAX FORMS (For electronic filing click here)

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By providing answers to the questions in the Health Assessment Questionnaire I request Andre A. Kulisz, PhD, ND, assistance to evaluate this Health Assessment Questionnaire and/or interview me to set up my individual health-enhancement program. 

I understand there is a fee of $75.00 for this evaluation (plus an additional fee for office appointment ($75.00 to $250.00 depending on complexity).  The completed questionnaire must be faxed to the number printed on the first form.  I will be informed of estimated office charges at the time of appointment. 

I understand, any nutritional supplements/formulations (if needed) will be billed separately with my separate permission.

• I understand that the resulting health-enhancement program is not a treatment.  It is also not intended as a substitute for regular medical care. 

• I understand, I retain the right to freedom of choice in health care and any other services.  This includes, but is not limited to my diet, purchase and/or use of any therapy, regimen, modality, remedy or product recommended by anyone of my choice.

• The enumeration in this declaration of these rights shall not be construed to deny or disparage the other rights retained by me, or my right to amend this declaration at any time.

To download the forms click on the following link: Health Assessment Questionnaire