Contact Holly

To schedule an appointment

please call 727-216-6929

Or E-mail Holly at

CountrysideIntegratedHealth@gmail.com

28467 US Highway 19 N., Suite 302
Clearwater, FL 33761

Please complete the following forms and bring them
with you to your first appointment.

• Patient Intake Form
• Patient Consent Form
• Patient Questionnaire
• Prescription Information Form
• Arbitration Agreement and Informed Consent Form
• Appointment Cancellation Policy
  
  

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Many of our patients have insurance benefits that cover treatment
in our office. Our patients pay at time of service and are then reimbursed by their insurance company. We will happily provide you with the appropriate paperwork to submit. We have provided an insurance verification form to help you when calling your insurance company to check on your benefits.

Insurance Verification Form

Holly Johantgen, DOM, AP
28467 US Highway 19 N.
Suite 302
Clearwater, FL 33761
727-216-6929
www.docholly.net
CountrysideIntegratedHealth@gmail.com