NSI ~ Nationwide Synergy, Inc.

Required Documents

		ONLINE Medical History Form You will need to print, sign, and fax to (561) 354-2744

		For Women Only!

Medication Management Agreement

Driver's License Copy
The law requires that you fax us a copy of your Driver's License to (561) 354-2744

Physical Examination Form

This form must be completed by a licensed physician in your state of residence, and faxed to (561) 354-2744.
You DO NOT need to fill out this form if you're scheduled to visit our clinic in Florida.

Traveling to the Clinic in South Florida?

Additional Forms:

	Credit Card Authorization
	An optional form that allows NSI to keep credit card information on file for future orders.

	List of Required Labs: Male
	A list of the laboratory tests NSI requires for all male patients.

	List of Required Labs: Female
	A list of the laboratory tests NSI requires for all female patients.

	Medical Records Release
	At NSI your records are confidential. A Medical Records Release is required if you are requesting that NSI send your records to another medical provider, or any third party.

NO TREATMENT WILL BE PROVIDED UNLESS A REVIEW OF YOUR MEDICAL HISTORY, PHYSICAL EXAMINATION, AND LAB TESTS REVEAL A NEED. COMPLETING THE REQUIRED MEDICAL HISTORY, LAB WORK AND PHYSICAL EXAMINATION DOES NOT AUTOMATICALLY QUALIFY YOU FOR THERAPY WITH NSI. ONLY OUR PHYSICIANS CAN DETERMINE IF YOU QUALIFY FOR TREATMENT.

The information provided on this website is not intended, nor should be construed as, medical advice. Please consult with your own physician or healthcare provider before starting any therapy program.