Patient Application

Welcome to DBC! To best serve you, we ask that you please select your desired service below and complete the detailed questionnaires. We really appreciate your investment of time to provide us insight into your health!
Please fill out the paperwork all at once or be sure to hit “Save Your Progress” so it all submits properly.

Dr. den Boer has carefully selected and extensively trained a team of providers, who are all available to serve you either through his direction or as your direct provider.

managed Holistic Care
acoustic Compression
health Coaching

Managed Holistic Care

I am honored and delighted you have contacted me about utilizing our services for your health needs! I have worked since 1989 to put a team in place to provide you with tools you need to help regain your health potential. Through his clinic,we offer you a wide array of services for health optimization, from chronic disease to everyday wellness to peak athletic performance.
Though incredible demand currently prevents Dr. den Boer from seeing new patients personally, my research, experience and expertise will be utilized on you throughout your journey to optimal health. I am happy to review the detailed information you provide on the following form and direct my team in the appropriate steps to start rebuilding your health. I will then follow your progress and continue to guide his team to provide you with the best care based upon your changing health needs.
Additionally, I have carefully selected and extensively trained the following providers, who are all available to serve you as your direct provider:
Dr. Stacey – One-onOne Holistic care and chiropractic services
Health Coaching – Lifestyle education programs, cooking classes, and more
Acoustic Compression – Treatment to heal acute and chronic injury, as well as inflammatory conditions

I look forward to working together with you soon!


Dr. Adrian J. den Boer

Comprehensive Holistic Care

Your DBC doctor will personally work with you to develop the best plan to optimize your health potential. They will coordinate a variety of services including consultation, chiropractic care, health coaching, and acoustic compression based on your needs. Based on availability, your initial appointment with your DBC doctor may be scheduled several months in the future.

Due to his years of research, experience and expertise, Dr. den Boer is continuing to work in close collaboration with his colleagues, Dr. Stacey Fischer and the highly trained staff of health coaches at DBC. This unique team approach to patient care allows new patients to benefit from Dr. den Boer’s knowledge while remaining under close supervision by his or her attending DBC doctor and other health providers.

Because DBC Natural Holistic Health Center is a cash practice, and we recognize these expenses come from your budget and not the insurance company, we are very open and up front regarding our services and pricing. Please review both our services and pricing available on the website.

Request a doctor

Chiropractic Care

DBC doctors are available to provide you chiropractic adjustments to repair your acute or chronic condition as well as the far reaching neurological and immune functions of an adjustment.

Health Coaching

DBC Health coaches are available to facilitate lifestyle changes to begin addressing the foundational elements of your health challenges, simply get yourself back on track, or if recommended by your DBC doctor. A variety of tools will be used including menu planning, stress management, recipes and exercise tips.

Acoustic Compression

Acoustic compression utilizes sound waves to promote the body’s healing process including acute or chronic conditions, circulation, reducing inflammation, and many, many more!

Please read and agree to HIPAA before proceeding

Notice of Privacy Practices

This notice describes how health information about you may be used and disclosed and how you can get access to this information. It applies to all protected health information contained in your health records maintained by us. We have the following duties regarding the maintenance, use and disclosure of your health records:

  1. We are required by law to maintain the privacy of the protected health information in your records and to provide you with this Notice of our legal duties and privacy practices with respect to that information.

  2. We are required to abide by the terms of this Notice currently in effect.

  3. We reserve the right to change the terms of this Notice at any time, making the new provisions effective for all health information and records that we have and continue to maintain. All changes in this Notice will be prominently displayed and available at our office.

There are a number of situations in which we may use or disclose to other persons or entities your confidential health information. Certain uses and disclosures will require you to sign an acknowledgement that you received this Notice of Privacy Practices. These include treatment, payment, and health care operations. Certain disclosures that are required by law, or under emergency circumstances, may be made without your Acknowledgement or Authorization. Under any circumstance, we will use or disclose only the minimum amount of information necessary from your medical records to accomplish the intended purpose of the disclosure.

We will attempt in good faith to obtain your signed Acknowledgement that you received this Notice to use and disclose your confidential medical information for the following purposes. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office once you have provided Consent.

Treatment: We will use your health information to make decisions about the provision, coordination or management of your healthcare, including analyzing or diagnosing your condition and determining the appropriate treatment for that condition. It may also be necessary to share your health information with another health care provider whom we need to consult with respect to your care. These are only examples of uses and disclosures of medical information for treatment purposes that may or may not be necessary in your case.

Payment: We may need to use or disclose information in your health record to obtain reimbursement from you, from your health-insurance carrier, or from another insurer for our services rendered to you. This may include determinations of eligibility or coverage under the appropriate health plan, pre- certification and pre-authorization of services or review of services for the purpose of reimbursement. This information may also be used for billing, claims management and collection purposes, and related healthcare data processing through our system.

Operations: Your health records may be used in our business planning and development operations, including improvements in our methods of operation, and general administrative functions. We may also use the information in our overall compliance planning, healthcare review activities, and arranging for legal and auditing functions.

There are certain circumstances under which we may use or disclose your health information without first obtaining your Acknowledgement or Authorization. Those circumstances generally involve public health and oversight activities, law-enforcement activities, judicial and administrative proceedings, and in the event of death. Specifically, we may be required to report to certain agencies information concerning certain communicable diseases, sexually transmitted diseases or HIV/AIDS status. We may also be required to report instances of suspected or documented abuse, neglect or domestic violence. We are required to report to appropriate agencies and law-enforcement officials information that you or another person is in immediate threat of danger to health or safety as a result of violent activity. We must also provide health information when ordered by a court of law to do so. We may contact you from time to time to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. You should be aware that we utilize an “open office environment” in which several people may be within earshot. We will try to speak quietly to you in a manner reasonably calculated to avoid disclosing your health information to others; however, complete privacy may not be possible in this setting.

Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your healthcare.

Communication Barriers and Emergencies: We may use and disclose your protected health information if we attempt to obtain consent from you but are unable to do so because of substantial communication barriers and we determine, using professional judgment, that you intend to consent to use or disclosure under the circumstances. We may use or disclose your protected health information in an emergency treatment situation. If this happens, we will try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If we are required by law or as a matter of necessity to treat you, and we have attempted to obtain your consent but have been unable to obtain your consent, we may still use or disclose your protected health information to treat you.

Except as indicated above, your health information will not be used or disclosed to any other person or entity without your specific Authorization, which may be revoked at any time. In particular, except to the extent disclosure has been made to governmental entities required by law to maintain the confidentiality of the information, information will not be further disclosed to any other person or entity with respect to information concerning mental-health treatment, drug and alcohol abuse, HIV/AIDS or sexually transmitted diseases that may be contained in your health records. We likewise will not disclose your health-record information to an employer for purposes of making employment decisions, to a liability insurer or attorney as a result of injuries sustained in an automobile accident, or to educational authorities, without you written authorization.

You have certain rights regarding your health record information, as follows:

  1. You may request that we restrict the uses and disclosures of your health record information for treatment, payment and operations, or restrictions involving your care or payment related to that care. We are not required to agree to the restriction; however, if we agree, we will comply with it, except with regard to emergencies, disclosure of the information to you, or if we are otherwise required by law to make a full disclosure without restriction.

  2. You have a right to request receipt of confidential communications of your medical information by an alternative means or at an alternative location. If you require such an accommodation, you may be charged a fee for the accommodation and will be required to specify the alternative address or method of contact and how payment will be handled.

  3. You have the right to inspect, copy and request amendments to your health records. Access to your health records will not include psychotherapy notes contained in them, or information compiled in anticipation of or for use in a civil, criminal or administrative action or proceeding to which your access is restricted by law. We will charge a reasonable fee for providing a copy of your health records, or a summary of those records, at your request, which includes the cost of copying, postage, and preparation or an explanation or summary of the information.

  4. All requests for inspection, copying and/or amending information in your health records, and all requests related to your rights under this Notice, must be made in writing and addressed to the Privacy Officer at our address. We will respond to your request in a timely fashion.

  5. You have a limited right to receive an accounting of all disclosures we make to other persons or entities of your health information except for disclosures required for treatment, payment and healthcare operations, disclosures that require an Authorization, disclosure incidental to another permissible use or disclosure, and otherwise as allowed by law. We will not charge you for the first accounting in any twelve-month period; however, we will charge you a reasonable fee for each subsequent request for an accounting within the same twelve-month period.

  6. If this notice was initially provided to you electronically, you have the right to obtain a paper copy of this notice and to take one home with you if you wish.

You may file a written complaint to us or to the Secretary of Health and Human Services if you believe that your privacy rights with respect to confidential information in your health records have been violated. All complaints must be in writing and must be addressed to the Privacy Officer (in the case of complaints to us) or to the person designated by the U.S. Department of Health and Human Services if we cannot resolve your concerns. You will not be retaliated against for filing such a complaint. More information is available about complaints at the government’s web site,

All questions concerning this Notice or requests made pursuant to it should be addressed to:

DBC Natural Holistic Health Center
2851 Michigan St. NE, Suite 101
Grand Rapids, MI 49506