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Legal Disclosure

We’re glad you’re taking this first step on your Road to Total Wellness! Please read through the terms below and check each section as indicated.

Click here if you wish to view and download the Legal Disclaimer & Scheduling Policy in PDF Format.

  • Print Full Name
  • All out of state and Tele Medicine consultations must be pre-paid. If you have not received PayPal invoice please text 219-613-1161 or email dp@21ctw.com: PIM (Which means please invoice me).

    Once your Health History, Health Appraisal Questionnaire and this Legal Disclosure form(s) are submitted you will receive email or text confirmation.

    Please text 219-613-1161 or email dp@21ctw.com to confirm your appointment date/time before arriving at our office.

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