Rejuvenate Wellness Center

6940 South Holly Circle

Centennial, CO 80112
303-850-0880

Dear friend,

Welcome to Rejuvenate Wellness Center!

Thank you and congratulations on making the choice to come see us!

You have scheduled an appointment with Dr. Peter M. Petropulos on ______

-------- (day/date> at (time) at our Rejuvenate Wellness Center
office.

Please complete all paperwork prior to arriving at the office and arrive 15 minutes
BEFORE your appointment time (which is listed above).

You have taken an important step and made the choice to turn either your own and/or
your family member's health around. We understand that this process will involve some
challenging lifestyle changes, and we are here to work together as partners with you to
help you reach your optimum health.

Many of our patients have previously consulted with numerous other health
practitioners. Your decision to partner with us in a quest to improve your health will
result in identifying the cause(s) of your illness, and eliminate the use of "Band-Aid"
treatments for your symptoms. Answers to some of the common questions/concerns by
our patients are listed below.

What Should I Do Prior to My Visit?

In this packet, you have received a health questionnaire. Take the time to answer the
questions with as much detail as possible. Please try to assemble any of your
medical information that may be helpful (tests, consultations with other
physicians, list of current medications and supplements). If you have had tests, lab
studies, surgeries, and/or consultations but don't have the records, please ask the
appropriate physicians and/or hospitals to give them to you or have them sent directly to
us. Bring the completed questionnaire and any additional information with you to your
appointment.

What If I Am on Any Medications or Supplements?

Please stay on them until we have an opportunity to review your complete history. Most
of our patients are able to eventually stop or reduce many of the medications that other
doctors have put them on after they have been on our program for awhile. At your initial
appointment, you will receive nutritional supplement recommendations. We carry an
extensive line of the finest supplements available to physicians anywhere. They are
specifically designed to complement the other lifestyle recommendations of our
program. Although you may be able to purchase similar products at local health food

Your Daily Food Intake Record: Track your dally eating pattems for one full week. including the
approximate amounts of each food. Bring this intake record with your first new patient appointment
Name: --------------------
Day 1 -
Breakfast (Time:._____,)
Meat& DaltY.________
Vegetab!e/Fru!t.________
Bread/CereaUGraln._______
Fats/Butter.______ ___
candy/Junk Food._______
Water Intake (fl. Oz..,______
Other Drinks.________
MID.YORNING SNACK (TIME:._ ___.
Snack.______________
Bowel Movements(# and Consistency)
Day2-
Breakfast (Time:._____
Meat&DaltY.________
Vegetable/Fruit,__________
Bread/Cereal/GraJn._______
Fats/Butter_____________
Candy/Junk food._________
Watertntake (fl. Oz.).______
Other Drinks.____________
MID-MORNING SNACK (TIME:.__
Snack.____________
Bowel Movements (# arid Consistency)
Day3-
Breakfast (Time:._____,
Meat&DeitY.________
Vegetae/Frult.__________
Bread/CereaUGraln._______
Fats/Butter.___________
Cendy/JunkFood.___________
Water Intake (fl. Oz.,______
Other Drinks.___________
MID-MORNING SNACK (TIME:.____,)
Snack.____________
Bowel Movements(# and Consistency)
The Rejuvenate Wellness Center
Lunch (Time:._____,
Meat & DalrY,________
Vegetable/Frult.________
Bread/Cereal/Grain._______
Fats/Butter.________
Csndy/JunkFood._____________
Water Intake (fl. Oz.),______
Other Drinks._________
MJD.DAY SNACK (TIME:.___
Snack1------------
Hours of Sleep:._____
Lunch (Time:._____,
Meat&DafJY.________
Vegetable/Fruit.______________
Bread/CereaJ/GraJn_________
. _
Fats/Butter___________
Candy/Junk Food..._______
Water Intake(fl. OZ.,______
Other Drinks.________
MID-DAY SNACK (TIME:.___
_,.1
Snack.___________________
Hours of Sleep:.________
Lunch (Time:.______
Meat&DalJY._________
Vegetable/Fruit.__________
Bread/Cereal/Grain._______
Fats/Butter.___________
Candy/Junk Food._______
Water Intake(fl. Oz.,______
Other Ortnka.__________
MID-DAY SNACK (TIME:.____)
Snack.____________
Hours of Sleep:._____
Check# Glaasea water
i.-i .... ...: :.r,,; Consumed Each Day
"""" "'"
Patient#:------
Dinner (Time:._____)
Meat&DaJJY.________
Vegatab1e/FNao.________
Bread/Cereal/Grain._________
Fats/Butter.______________
Candy/Junk Food.________
Water Intake(ft. Oz..,_______
Other Drinks,:________
NIGHmME SNACK (TIME:.___,
Snack._____________
Quality of Sleep: _______
Check# Glasses Water
Consumed Each Day
Dinner (Time:._____,
Meat & Dairy________
VegetablelFrult:..-------
Bread/CereaUGrafn:..-------
Fats/Butter_________
Candy/Junk Food,________
Water Intake (fl. Oz.,______
Other Drfnks._________
NIGHmME SNACK (TIME:.___,
Snack._________ __
Quality of Sleep: _______
Check# Glasses Water
Consumed Each Day
Dinner (Time:._____)
Meat& Da!JY.____________
Vegetable/Fruit.__________
Bread/CereaUGrafn._______
Fats/Butter____
, ______
Candy/Junk Food._______
Water Intake(fl. Oz.,______
Other Drinks,_________
NIGHTIIME SNACK (TIME:.____,
Snack.__________
Quality of Sleep: _______
.....
 The Rejuvenate Wellness
Center
6940 S. Holly Cir. #201
Centennial, CO 80112
303-850-0880
www.rejuvenatewellnesscenter.com

PATIENT- DOCTOR AGREEMENTS

The purpose of these agreements is lO allow us to more completely serve you and to get the best results
in the sho11est amount of time. Our experience is that Lhose patients who adhere to the following agreements.
gel the best results.

PAYMENT OF BILLS-
Whatever arrangements you make with our office. we expect you to honor. If you eant fulfill your
arrangement in this area. please let our financial manager know immediately so new a1nngc111cnts can be made.
Accounts past clue \\'ill be charged a handling fee. Failure to communicate after three billings in the form of
payment or explanation will result in immediate legal action.

FTRST APPOINTMENT ARRTVAL-

Tn order to honor your time and the time of our other patients. please arrive J 5 minutes prior LO your
initial appointment with!!! of your New Patient forms completed preceding your arrival. This will allow the
f
office staf Lo assemble your patient chart and pennit Dr. Petropulos to review all of your health history
information prior to the start of your appointment Lime. We feel that lhis is extremely important, so strict
adherence to this expectation is required.

CANCELLING OR CHANGING APPOINTMENTS-

We ha\"C set up a specific course of treatment for you. A certain amount of treatments are required in a
set amount of time to get the results we both desire. Thus, if you need to change the time of your appointment,
attempt to come in anotJ1cr time the same day. If you are unable to keep your appointment within the same day,
we require 24 hour notice, otherwise you will be charged for the time reserved.

WAITTIME-
Due 10 the inability to predict patient needs, appointments may take longer than anticipated. Waiting
can be expcctc<l. Please feel free to call our office prior to your appointment to sec how the doctor is running.
Every attempt to predict wait time will be made at the time of your call. Please feel free to communicate any
frustrations concerning this directly to the doctor.

PERFUMES, LOTIONS AND COLOGNES-

For the comfort of our office staff and patients, please refrain from wearing any perfume, cologne. or
strongly scented lotions when visiting our office. Many of those with whom you will be in contact suffer from
allergies to the above referenced items. Your cooperation in this is greatly appreciated!

DIETS AND FOOD SUPPLEMENTS-

Both should be followed or taken as requested by your doctor. Please communicate any inability Lo do
such, so that the doctor can compensate for any nulTitional inadequacy.
You arc expected to pay for v1tamins at the time of purchase.

Patient Signature Date

 HIPAA Notice of Privacy Practices

The Rejuvenate
Wellness Center
Dr. Peter M. Petropulos
6940 S. Holly Cir. #201
Englewood, Co. 80112

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices describes how we may use and disclose your protected health Information (PHI) to carry out
treatment. payment or health care operations (TPO) and for other purposes that are.pennitted or required by law. It also describes
your protected health Information. Protected health information is information about you, including demographics Information, that
may Identify you and that relates to your past. present or future phystcal or mental health or condition and related health care
services.
1. Uses and Disclosures of protected Health Information
Uses and Disclosures of Protected Health Information
Your protected health infonnatlon may be used and disclosed by your physician, our office staff and others outside of our office that
are fnvolved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to
support the operation of the physician's practice. and any other use requfred by law.
Treatment We will use and disclose your protected health information to provide, coordinate, or manage your health care and any
related services. This includes the coordination or management of your health care with a third party. For example, we would
disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your
protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the
necessary information to diagnose or treat you.
Payment: Your protected health Information will be used, as needed, to obtain payment for your health care services. For example,
obtafning approval for a hospital stay may require that your relevant protected health fnfonnation be disclosed to the health plan to
obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as-needed, your protected health fnfonnatlon In order to support the business
activities of your physician's practice. These activities include. but are not limited to, quality assessment activities, employee review
activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may
disclose your protected health infOffllation to medical school students that see patients at our office. In addition, we may use a sign
in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by
name in the waiting room when your physician is ready to see you. We may use or disclose your protected health fnfonnation, as
necessary, to contact you to remind you of your appointment
We may use or disdose your protected health Information in the fottowlng situations without your authorization. These situations
Include: as Required By Law, Public Health issues as required by law, Communicable Diseases: Health Oversight Abuse or
Neglect: Food and Drug Administration requirements: Legal Proceedlngs: Law Enforcement Coroners, Funeral Directors, and
Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers' Compensation: Inmates: Required
Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of
Health and Human Services to Investigate or determine our compliance with the requirements of Section 164.500.
Other Pennltted and required Uses and Disclosures WUI Be Made Only With Your Consent, Authorization or Opportunity to
Object unless required by Law.
You may revoke this authorization, at any time, In writing, except to the extent that your physldan or the physician's practice has
taken an action in reliance on the use or disclose Indicated In the authorization.
Your Rights
Following is a statement of your rights with respect to your protected health lnfonnation.
You have the right to Inspect and copy your protected health lnfonnatlon. Under federal law, however, you may not Inspect or
copy the following records; psychotherapy notes; lnfonnation compOed In reasonable anticipation of, or use In, a civil, criminal, or
administrative action proceeding, and protected health infonnation that Is subject to law that prohibits access to protected health
lnfonnation.
You have the right to request a restriction of your prptectad health Information. This means you may ask us not to use or
disclose any part of your protected health Information not be disclosed to family members or friends who may be Involved In your
care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction
requested and to whom you want the restriction to apply.
Your physician Is not required to agree to a restriction that you may request. If physician believes it Is In your best interest to pennlt
use and dlsctosure of your protected health lnfonnatlon, your protected health lnfonnatlon will not be restricted. You then have the
right to use another Healthcare Professional.
You have the right to request to receive confidential communications from us by alternative means or at an alternative
location. You have the right to obtain a paper copy of this notice from us. upon request, even if you have agreed to accept
this notice alternatively i.e. electronically.

You may have the dght to have your physician amend your protected health lnfonpaQon. If we deny your request for
amendment. you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will
provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made. If any. of your protected health
Information.
We reserve the right to change the terms of this notice and will inform you by mall of any changes. You then have the right to object
or withdraw as provided In this notice.
Complalnts
You may compfaln to us or to the Secretary of Health and Human Services If you believe your privacy rights have been violated by
us. You may file a complaint with us by notifying our privacy contact of your complaint We will not retaliate against you for fifing
a complaint.

This notice was pubfished and becomes effective on/or before April 14. 2003.

We are required by law to maintain the privacy of, and provide Individuals with, this notice of our legal duties and
privacy practices with respect to protected health infonnation. If you have any objections to this fonn, please ask to
speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.

Signature below is only acknowledgment that you have received this Notice of our Privacy Practices:

Print Name________________ Signature._____________

Date________________________