You are here Home » NEW Client Form

NEW Clients

Please complete and submit BEFORE scheduling online.

NEW Client Instructions

FORM COMPLETION: Thank you for completing the confidential and secure form below. After clicking the SUBMIT FORM button at the bottom of this page, you will be redirected to online booking.

PRE-PAYMENT: When you get to online booking, you'll notice that we ask for pre-payment. This makes checking out easy after your visit. What cards are acceptable? Debit, credit, Health Savings Account (HSA), or Flex Spending Account (FSA) cards. Note that third-party payers (health insurance plans and Medicare) are not covering Sinus Ninja Treatments™ at this time. Prefer to book by phone? Call Us!

CANCELLATION / LATENESS POLICY: Cancels and reschedules with less than 24 hours notice cannot be refunded. Lateness past 15 minutes may be considered a missed appointment, at the clinician's discretion.

SUBMIT FORM: After clicking the SUBMIT FORM button at the bottom of this page, you will be redirected to online booking. Questions or problems? Call Us!

* Required Fields

First Name

Last Name

Occupation

Date of Birth

Age

Address

City

State

Zip

Phone

Emergency Contact

Emergency Contact Phone

* Referral From

Referrer Name

Main Concern

ROS Description

Medications

Allergies

Sinus Problem

Informed Consent

By checking this box, I ATTEST I have read and understood the following statement, and give my consent to receive treatment by Nova Sinus Center, LLC (Sinus Ninja):

The Sinus Ninja Treatment™ is a safe and effective all-natural topical therapy that intends to provide immediate and lasting nose and sinus relief. Like taking a course of antibiotics, treatments are MOST effective as an initial series followed by maintenance treatments.

An initial series of (4) weekly treatments is advised.  After the initial series, (1) maintenance treatment each month is advised to maintain a symptom-reduced quality of life. 

NEBULIZER: The treatment starts with inhalation of a soothing mist while your face is supported in a forward-reclining massage chair. Allicin nebulization, the breathing-in of garlic isolate vapors, is a safe and routine naturopathic procedure. It is highly effective in cases of sinusitis, seasonal allergies, and when general anti-microbial/anti-inflammatory effect on the mucus membranes of the respiratory passages is indicated. The vapor also includes xylitol (a sugar alcohol) and 0.9% saline. For added antiviral benefit, the vapor will also include silver hydrosol. You will be instructed to breathe the fine mist vapors for (5) minutes with your face resting in a sanitized breathing mask. SINCE ALLICIN IS A NATURAL DERIVATIVE OF GARLIC, BE SURE TO ALERT YOUR CLINICIAN IF YOU HAVE GARLIC OR ONION ALLERGIES.

SWAB PLACEMENT: Next, sterile swabs soaked with all-natural plant essences of red thyme, eucalyptus, lavender, and peppermint, diluted with grapeseed, are placed gently and expertly inside the nose, close to the sinus openings. The placement of volatile oil-soaked swabs into the nasal passages, is a safe and routine naturopathic procedure. It is highly effective in cases of sinusitis, and when general anti-microbial effect on the mucus membranes of the nasal passages is indicated. After placement, swabs remain in place for (10) minutes while your face is supported in a forward-reclining massage chair. Complications can occur, however, which include but are not limited to: temporary irritation within the nasal passages; temporary sneezing and nasal drainage; lightheadedness from volatile oil vapors; and nasal artery and/or vein trauma leading to temporary or sustained nosebleed. BE SURE TO ALERT YOUR CLINICIAN IF YOU HAVE SEED ALLERGIES (GRAPESEED), ALLERGY OR SENSITIVITY TO ANY PLANT ESSENCES (THYME, LAVENDER, EUCALYPTUS, PEPPERMINT), HIGH BLOOD PRESSURE, ANY BLEEDING DISORDERS, OR IF YOU ARE TAKING A BLOOD THINNING MEDICATION SUCH AS COUMADIN (WARFARIN), LOVENOX (ENOXAPARIN) INJECTIONS, PRADAXA (DABIGATRAN), ELIQUIS (APIXABAN) OR XARELTO (RIVAROXABAN).

SPRING ACTIVATOR

Following removal of the swabs, enjoy a few minutes of soothing bodywork including spring activation of points on the upper back related to the nose and sinuses.

DISCLAIMER: Like many interventions in medicine, the alternative treatment offered at Nova Sinus Center, LLC is empirical. That is, we "try it" to see if it works. No promise of result is implied or intended. I hereby understand, agree, and affix my electronic signature by entering my first and last name at the bottom of this page.

Cancel Policy

By checking this box I UNDERSTAND that cancellations and reschedules made with LESS THAN 24 HOURS NOTICE CANNOT BE REFUNDED.

Lateness Policy

By checking this box I UNDERSTAND that LATENESS past 15 MINUTES may be considered a MISSED appointment, at the clinician's discretion. Thank you for checking-in 10 minutes before your appointment time.

Signature First Name

Signature Last Name

Remember to Click the Submit Form button above to be redirected to Online Booking. Thank You!

NEW Clients

Please complete and submit BEFORE scheduling online.

NEW Client Instructions

Get Started

Get a treatment

Compare

About Us