Dr. Jodi Sampson, D.C.

Finding Balance

Patient Forms

Your first steps as a patient are to complete the Patient Information Form which you can find right here:

Patient Information Form.

Once you have completed your Patient Information Form you will then need to complete the various forms listed below. Once you have printed and completed these forms please call the office to submit forms at (507) 401-2772.

Forms to Be Printed

Please print out and complete these forms. Once completed please schedule a time to submit your forms to the office during our scheduled office hours.

Healthy History Intake Form 
Metabolic Assessment Form 
Detoxification Questionnaire 
Informed Consent                                     

Neurotransmitter & Nutrition Questionnaire (children’s form only, not applicable for adults)

Virtual Consult Authorization Form (Virtual Patients, ONLY)

Only If Required

The Health Assessment Form is not required to be filled out by all patients. Dr.Jodi Sampson will let you know if this form is one that you will need to fill out and submit. This form is very EXTENSIVE.