Patient Forms - Dr. John Salerno

A person is holding a patient registration form in their hand, representing Patient Forms for Dr. John Salerno

 Medical Patient Treatment Forms for Salerno Wellness in Manhattan, NY and Connecticut

Please take the time to fill out, print, and bring with you the appropriate patient treatment form in advance of your visit. This will help us expedite you wait time so we can focus on your treatment. Please contact us if you have any questions filling out any of the forms. I sincerely look forward to seeing you!

-Dr. John Salerno

Patient Registration

Patient Registration Form
Download Registration Form

Medical Release (HIPPA)

Download HIPPA Form

HBOT Consent Form

Informed Consent for Hyperbaric Oxygen Therapy
HBOT Consent Form

Insurance Payment Agreement

Informed Consent for Hyperbaric Oxygen Therapy
Insurance Payment Agreement

*Hyperbaric Oxygen Therapy (HBOT)

Booking and Cancellation Policy


At Salerno Wellness, we are committed to providing every patient with the highest level of care, comfort, and attention. To ensure that our schedule remains available and fair to all patients, we kindly ask that you review and agree to the following booking policy before scheduling your appointment:

 

Credit Card Requirement

 

  • All appointments require a valid credit card on file at the time of booking.
  • Your card will not be charged at the time of booking, except in the case of a missed appointment (see below).


Cancellation Policy

 

  • New Patients: A 48-hour cancellation notice is required. 
  • Established Patients: A 48-hour cancellation notice is required. 

 

Consequences for Missed Appointments 


  • No-Show Fee: for NEW PATIENTS - A $100 fee will be charged to your credit card on file if you fail to attend your appointment without notice. 


  • Missed Appointment Fees: for ESTABLISHED PATIENTS -  A $75.00 fee will be charged to your credit card on file if you fail to attend your appointment without notice. 

 

Policy Acknowledgement

 

By booking an appointment, you acknowledge and consent to this policy and authorize the center to charge the no-show fee. 


We thank you for your cooperation and understanding, as this policy helps us respect our practitioners’ time and better serve our patients.