patient centEr

We know that your time is valuable, to help speed up the registration process, we ask that you complete these forms online. By filling out these forms before your first visit, we can keep the time you spend at the reception as short as possible. In addition, please bring any your insurance card, co-payment, and all medications you are taking currently. Also, if you have a copy of your current medical record, please bring it, we can also help you fill out a form requesting the transfer of your medical record.

Now you can easily pay your statement balance online.

Click to pay through our secure merchant below. Please allow up to 5 days for your payment to reflect on your account.

Forms Center

Coming in for the first time? Please fill out all of these forms before your visit.

JOurney to Wellness - FORMS PACK

Journey to Wellness

Please fill out the Journey to Wellness package of forms.

Estimated Completion Time: 45 minutes

Practice Policy & Notices

Policy & Disclosure Forms

This form package contains HealnCure's financial policy, Medical records policy and a notice of how we will use your Health Information.

  • Financial Policy & Consent
    1 Page
    Heal n Cure's Financial Policy
  • Release of Medical Records
    1 Page
    Authorization for releasing medical records
  • HIPAA Privacy Notice
    1 Page
    Our HIPAA Policy and how we will use your Health Information
  • HIPAA Consent Form
    1 Page
    Your consent to our HIPAA Privacy Policy

Optional Forms

Pellet Consent Form

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  • Pellet Consent for Male Patients
    1 Page
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  • Pellet Consent for Female Patients
    1 Page
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Patient Registration

Patient Medical History

Impact of Medical Conditions

Depression Screening Form

Eating Pattern & Behavior

Hormone Deficiency Assessment

Financial Policy Consent

Neurotransmitter Assessment Form

Release of Medical Records

Metabolic Detoxification Questionnaire

Medication History

HIPAA Consent Form

Hormone Restoration Forms

Pellet Consent for Male

Pellet Consent for Female

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  • Date Format: MM slash DD slash YYYY
    ( Check all that apply )

Patient Registration


  • Employment Information:


  • Emergency Contact :



  • Secondary Emergency Contact :



  • Primary Care Provider (PCP) :


Impact of Medical Conditions

  • Impact of Medical Conditions on Your Life

  • Date Format: MM slash DD slash YYYY
  • How does this problem interfere with the following areas in your life?

  • Rate on a scale of 1-10

Hormone Deficiency Assessme

Your Wellness Journey Starts here.
  • Date Format: MM slash DD slash YYYY
  • Fill up the details promptly below so as to analyze if you need any treatment related to hormone deficiency.
  • TESTOSTERONE

  • Signs and symptoms ( Men and Women )
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
  • Signs and symptoms ( Men Only )
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
  • Score for Women: [5 or less : Satisfactory level] [6-10 : Possible Testosterone deficiency] [11 or more : Probable Testorsterone deficiency ] Score for Men: [ 10 or less: Satisfactory level ] [ 11 to 20 : Possible Testorsterone deficiency ] [ 21 or more : Probable Testorsterone deficiency ]
  • ESTROGEN

  • Signs and symptoms
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : (0=moderate I 1-3=1ow / 4=none)
    Select any one option on a scale : (<27 days),or too long (>31 days)
    Select any one option on a scale : 0 being Never to 4 being Always
  • The overall total of 10 or less is satisfactory level. Between 11-20: Possible Estrogen deficiency. 21 or more: Probable Estrogen deficiency.
  • PROGESTERONE

  • Signs and symptoms
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
  • [The following questions are for women who have not yet reached menopause, and menopausal women who are taking hormone replacement therapy (estrogen or estrogen and progesterone).]
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
  • Post-menopausal women not treated with hormone replacement therapy (estrogen or estrogen and progesterone): 4 or less: Satisfactory level. Between 5 and 8: Possible Progesterone deficiency. 9 or more: Probable Progesterone deficiency ------- Menstrual women and menopausal women taking hormone replacement therapy (estrogen or estrogen and progesterone): 10 or less: Satisfactory level. Between 11 and 20: Possible Progesterone deficiency. 21 or more: Probable Progesterone deficiency
  • THYROID

  • Signs and symptoms
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
  • The overall total is 10 or less is satisfactory level. Between 11-20: Possible Thyroid Hormone deficiency. 21 or more: Probable Thyroid Hormone deficiency.
  • DHEA

  • Signs and Symptoms ( Men and Women )
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    (0 = plenty of hair/ 4 = hairless)
    (flat "mound ofVenus" in women). (0 = padded/4 = flat)
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
    Select any one option on a scale : 0 being Never to 4 being Always
  • The overall total is 10 or less is satisfactory level. Between 11-20: Possible DHEA deficiency. 21 or more: Probable DHEA deficiency

Financial Policy Consent

  • FINANCIAL POLICY

  • It is your responsibility to know if your insurance has specific rules or regulations,such as the need for referrals,recertification's, preauthorization's, limits on outpatient charges, specific physicians and/or hospitals to use. You should be knowledgeable of any deductibles, copayments, and/or coinsurance. This applies to all payers regardless of whether or not our physicians participate.
  • The responsibility for payment of fees for services is your direct responsibility. Your health benefit plan is an arrangement between you,the enrollee, and the insurance company or your employer. We will do our best to assist you with understanding your proposed treatment and in answering questions related to your insurance.

    Please check all boxes below to acknowledge you have read the financial policy
  • Payment Policy Schedule


  • Other charges/fees*

  • *subject to change at any time


  • We require you to provide us with 24 hour notice for prescription refill during the weekday. The requests made over the weekends and holidays will be filled the following business day. we need minimum of five day notice to fill out any paperwork.

    Should you have any questions with regard to our financial policy we encourage you to ask.

    We ask that you present the correct and updated contact and medical insurance information at the time of each visit. Please notify the receptionist of any changes during the subsequent visits promptly.
  • Date Format: MM slash DD slash YYYY

Neurotransmitter Assessment Form

Your Wellness Journey Starts here.
  • Date Format: MM slash DD slash YYYY
  • SECTION A

    Select any one option on a scale : 0 being Never to 3 being Always
  • SECTION B

  • SECTION C

    Section C1
  • Section C2
  • SECTION D

  • SECTION E

  • SECTION F

  • SECTION G

Metabolic Detoxification Questionnaire

Your Wellness Journey Starts here.
  • Point Scale
    • 0 - Never or Almost never have the symptoms
    • 1 - Occasionally have it, effect is not severe
    • 2 - Occasionally have it, effect is severe
    • 3 - Frequently have it, effect is not severe
    • 4 - Frequently have it, effect is severe
      • Date Format: MM slash DD slash YYYY
      • Head

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Eyes

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Ears

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Nose

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Mouth / Throat

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Skin

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Heart

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Lungs

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Digestive Tract

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Joints/ Muscles

      • Weight

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Energy/ Activity

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Mind

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Emotions

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Other

      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.
      • Please enter a number from 0 to 4.

Medication Histroy

Your Wellness Journey Starts here.
  • Please check any of the following medications you have taken in the past or are currently taking.
  • Date Format: MM slash DD slash YYYY

Privacy Notice

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.

OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. This Notice applies to all records of your care generated and maintained by Heal n Cure, SC. Your hospital or non-Heal n Cure, SC providers may have different policies or notices about the use and disclosure of information in their possession. We are required by law to: 1) make sure that medical information that identifies you is kept private; 2) make available to you this Notice of our legal and privacy practices with respect to medical information about you; and 3) follow the terms of the Notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU

  1. We may disclose medical information about you to doctors, nurses, medical
    students, or other Heal n Cure, SC personnel involved in taking care of you. We
    may also disclose medical information to people outside the medical group, such
    as family members, specialists or others who are involved in providing services
    that are part of your care
  2. We may use or disclose medical information about you so that the treatment and
    services you receive at Heal n Cure, SC may be billed to and payment may be
    collected from you, an insurance company or a third party.
  3. We may use or disclose medical information about you for Heal n Cure, SC
    operations. These may include use of information to evaluate the performance of
    our staff, effectiveness of programs, and ways to improve care and services we
    offer. These uses and disclosures are necessary to ensure that all of our patients
    receive quality care.
  4. We may use and disclose medical information to contact you as a reminder that
    you have an appointment for treatment or care at Heal n Cure, SC.
  5. We may use or disclose medical information to tell you about or recommend
    possible treatment options or alternatives, and about health-related benefits and
    services that may be of interest to you.
  6. We may disclose medical information about you to other healthcare providers in
    the event you need emergency care.
  7. We will disclose medical information about you as required by federal, state or
    local law.
  8. We may use or disclose medical information to a public health organization or
    federal organization when necessary to prevent a serious threat to your health
    and safety or the health and safety of the public or another person.
  9. We may use or disclose medical information about you in special situations such
    as for workers’ compensation programs, as required by military command
    authorities or the Department of Veterans Affairs, in response to a court or
    administrative order, or for public health activities.
  10. Other uses and disclosures of medical information not covered by this Notice or
    the laws that apply to us will be made only with your written authorization. You
    may later revoke this permission in writing, at any time.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

  1. You have the right to review and receive a copy of medical information that may
    be used to make decisions about your care. Usually this includes medical and
    billing records, but does not include psychotherapy notes. You must submit a
    written request to review and copy your medical information. We may charge a
    fee for the costs of supplying a copy of the records.
  2. You have the right to ask us to amend medical information that you feel is
    incorrect or incomplete. Your request for an amendment must be submitted in
    writing and must provide a reason that supports your request.
  3. We may deny your request for amendment if it is not in writing or does not
    include a reason to support the request. In addition, we may deny your request if
    the information: 1) was not created by us; 2) is not part of the medical information
    kept by or for Heal n Cure, SC; 3) is not part of the information which you are
    permitted to inspect and copy; or 4) is accurate and complete.
  4. You have the right to request an “accounting of disclosures.” This is a list of
    disclosures we have made of medical information about you, with some
    exceptions. The exceptions are governed by federal health privacy law, and
    include: 1) routine disclosures for treatment, payment and operations conducted
    pursuant to your signed consent form; and 2) disclosures to you. You must
    submit a written request. The request must state a time period that may not be
    longer than six years and may not include dates before April 14, 2003, when
    current federal health privacy laws become effective for Heal n Cure, SC.
  5. You have the right to request restrictions or limitations on the use or disclosure of
    medical information about you. You must submit a written request for restriction
    that specifies: 1) what information you want to limit; 2) whether you want to limit
    our use, disclosure, or both; and 3) to whom you want the limits to apply. Heal n
    Cure, SC reserves the right to refuse your restriction if it is in conflict of providing
    you quality healthcare or in an emergency situation.
  6. You have the right to request that we communicate with you about medical
    matters in a certain way or at a certain location, such as only at work or by mail.
  7. You must submit a written request for confidential communications restrictions,
    specifying how or where you wish to be contacted. We will accommodate
    reasonable requests.
  8. You have the right to possess a copy of this Privacy Notice upon request. You
    may receive a paper copy of this notice, or you can also obtain a copy of this
    Notice at our website, www.healncure.com
  9. You have the right to file a complaint with Heal n Cure, SC if you believe your
    rights to privacy have been violated. All complaints must be submitted in writing
    to the Office Manager at our clinic address. All complaints will be investigated.
    No personal issue will be raised for filing a complaint.

CHANGES TO THIS NOTICE
Heal n Cure, SC reserves the right to change this Notice at any time. We will post a copy
of the current notice in our clinic and on our website.

HIPAA Consent

  • Heal n Cure, SC www.healncure.com
    Meena Malhotra, MD Phone: 847-686-4444 Fax: 847-686-9999
  • I hereby acknowledge the receipt and complete understanding of Notice Of Privacy Practices of Heal n Cure, SC which provides detailed information about how the practice may use and disclose my confidential information.
    I understand that Heal n Cure has reserved the rights to change its privacy practices that are described in the Notice. I also understand that a copy of any revised notice will be provided to me or made available at the subsequent visit to the clinic.
  • Date Format: MM slash DD slash YYYY
  • If you are not the Patient, please verify your relationship to the patient.

  • Date Format: MM slash DD slash YYYY

PELLET CONSENT MALE

  • I have disclosed accurate and true information regarding my medical history, medication history and surgeries. I understand that bio-identical hormone estrogen and/or testosterone replacement pellet insertion is a minor surgical procedure. I consent to this procedure. The procedure has been explained to me. I understand that as with any surgical procedure there are risks to the patient and no treatment or procedure is ever deemed 100% safe. I understand that the following are rare but a possibility as a result of this procedure:
  • Acne Growth of preexisting estrogen dependent tumors
    Area infection Increased facial hair growth
    Area Swelling Loss of hair on scalp
    Bleeding Minor discomfort/pain
    Bruising/ Soreness Minor or slight scarring at the incision site
    Deepening of voice Pellet extrusion
    Discoloration of the skin
  • I understand that once the pellet(s) have been inserted they cannot be removed. I understand that it takes most patients approximately 24 to 72 hours after the pellet insertion for the hormones to become active in the patient’s system. I agree to follow the written post-surgery instructions I am given. I understand that if I am not menopausal, I will continue a reliable birth control method. I understand that in addition to pellet therapy, I may require additional medication such as sublingual or oral progesterone.
  • I understand, and agree, to immediately contact the Heal n Cure staff at (847) 686-4444 if I experience partial or full pellet extrusion (exiting the body), excessive area pain, excessive bleeding and/or wound infection. I also agree that if I fail to report the previously mentioned situations that I will not hold Meena Malhotra M.D. liable for any negative physical, emotional or mental outcome. Either Dr. Malhotra, or a staff member, has explained and reviewed alternative methods of hormone replacement, and I understand that I have options. I request that the procedure be performed today
  • Make sure you enter this Email correctly as we will be sending you a filled PDF form to this Email Id to get Witness Signature on it.

PELLET CONSENT FEMALE

  • I have disclosed accurate and true information regarding my medical history, medication history and surgeries. I understand that bio-identical hormone estrogen and/or testosterone replacement pellet insertion is a minor surgical procedure. I consent to this procedure. The procedure has been explained to me. I understand that as with any surgical procedure there are risks to the patient and no treatment or procedure is ever deemed 100% safe. I understand that the following are rare but a possibility as a result of this procedure:
  • Acne Growth of preexisting estrogen dependent tumors
    Area infection Increased facial hair growth
    Area Swelling Loss of hair on scalp
    Bleeding Minor discomfort/pain
    Bruising/ Soreness Minor or slight scarring at the incision site
    Deepening of voice Pellet extrusion
    Discoloration of the skin Transient and Reversible Swelling of the labia and clitoris
    Transient breast tenderness/swelling
  • I understand that once the pellet(s) have been inserted they cannot be removed. I understand that it takes most patients approximately 24 to 72 hours after the pellet insertion for the hormones to become active in the patient’s system. I agree to follow the written post-surgery instructions I am given. I understand that if I am not menopausal, I will continue a reliable birth control method. I understand that in addition to pellet therapy, I may require additional medication such as sublingual or oral progesterone.
  • I understand, and agree, to immediately contact the Heal n Cure staff at (847) 686-4444 if I experience partial or full pellet extrusion (exiting the body), excessive area pain, excessive bleeding and/or wound infection. I also agree that if I fail to report the previously mentioned situations that I will not hold Meena Malhotra M.D. liable for any negative physical, emotional or mental outcome. Either Dr. Malhotra, or a staff member, has explained and reviewed alternative methods of hormone replacement, and I understand that I have options. I request that the procedure be performed today
  • Make sure you enter this Email correctly as we will be sending you a filled PDF form to this Email Id to get Witness Signature on it.