MidSouth Integrative New Patient Interest Form

Want to become a new patient? Please fill out the information below and our team will be in touch.
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Please note you can choose to opt-out at any time.

Privacy Policy:


By submitting this form, you agree that the information you provide may be used by MidSouth Integrative Medical to contact you about your care, appointments, and related services.

If you provide your mobile number and opt in, you consent to receive SMS/text messages from us, including appointment reminders, important updates, and occasional marketing or promotional messages. Message and data rates may apply. Message frequency may vary. You can opt out of SMS at any time by replying STOP to any message. Your SMS consent and mobile number are not sold or shared with third parties, and are only disclosed to our contracted SMS service providers as necessary to send messages on our behalf. We respect your privacy and protect your information in accordance with applicable laws and our internal privacy practices. Do not use this form to share urgent medical questions or sensitive health information. For medical emergencies, call 911; for medical questions, please contact our office directly.

Terms of Service


Last updated: February 24, 2026


Please read these Terms of Service (“Terms”) carefully before using the website and online forms of MidSouth Integrative Medical. By accessing or using our website, submitting a form, or otherwise interacting with us online, you agree to be bound by these Terms.


If you do not agree with these Terms, do not use our website.


1. Who We Are


MidSouth Integrative Medical is an integrative medical, aesthetic, and chiropractic clinic providing whole-person care, blending traditional medicine, functional medicine, aesthetic services, and chiropractic care under medical supervision.


We are a faith-informed, values-driven practice. While prayer and spiritual support may be offered when appropriate and desired, all patients are welcome and receive the same level of professional care regardless of personal beliefs.


2. Not Medical or Emergency Advice


The content on this website (including articles, videos, graphics, social media, and messages) is for general informational and educational purposes only and does not constitute medical advice, diagnosis, or treatment.


Do not rely on this website as a substitute for an in-person evaluation by a licensed healthcare provider.


Use of this website does not create a patient–provider relationship.


If you have a medical concern, please contact our office directly or speak with your own healthcare provider.


In a medical emergency, call 911 immediately. Do not use this website, online forms, SMS messages, or email for emergencies.


3. Eligibility and Patient Relationship


You must be at least 18 years old to use this website or submit forms on your own behalf. Parents or legal guardians may use the website on behalf of a minor child for scheduling or inquiries.


A formal patient relationship with MidSouth is established only when you have been accepted as a patient, have completed necessary documentation, and have been seen or directly consulted by one of our licensed providers. Use of this website alone does not establish you as a patient.


4. Use of the Website and Online Forms


You agree to use our website and forms only for lawful purposes and in a manner consistent with these Terms.


By submitting any information through our forms, you represent that:


The information you provide is accurate and complete.


You are submitting information about yourself, or you are authorized to submit information on behalf of another person (such as your minor child).


You will not use the website to transmit any harmful, unlawful, abusive, or otherwise inappropriate content.


We reserve the right to refuse or terminate access to the website for any user who violates these Terms or misuses the site.


5. Communications and SMS/Text Messaging


By providing your contact information (including phone number and/or email) through our website or in our office, you consent to us using that information to communicate with you regarding:


Appointment scheduling, confirmations, and reminders


Care coordination and follow-up (where appropriate)


Service updates, clinic information, and operational notices


Marketing or promotional messages about services, events, or special offers (if you opt in)


If you provide your mobile number and explicitly consent (e.g., by checking a box or signing a consent), you agree to receive SMS/text messages from MidSouth, which may include both transactional and promotional messages. Message and data rates may apply. Message frequency may vary.


You can opt out of SMS/text messages at any time by replying STOP to any text from us. You may also contact our office to update your communication preferences.


SMS Privacy:

Your SMS consent and mobile number are not sold or shared with third parties. We may share your mobile number only with our trusted SMS service providers as needed to send messages on our behalf; those providers are contractually obligated to safeguard your information and use it only for this purpose.


SMS and email communications may not always be fully secure. Please avoid sharing highly sensitive personal or medical information via SMS or standard email.


6. Privacy and Data Protection


We take your privacy seriously and strive to protect your personal information in accordance with applicable laws and our internal privacy practices.


Information you submit through this website may be used to respond to your requests, schedule appointments, coordinate services, and communicate with you.


Depending on the nature of the information and your relationship with us, some data may be treated as part of your medical record and protected under health privacy laws.


We may also use de-identified or aggregated information to help improve our services, operations, and website.


This Terms of Service page is not a complete description of our privacy practices. Additional details may be provided in a separate Notice of Privacy Practices or Privacy Policy available through our office or website. In the event of a conflict, the Notice of Privacy Practices governing protected health information will control.


7. Appointments, Cancellations, and Payments


Any descriptions of services, pricing, membership programs, or payment policies on this website are for general informational purposes and may change at any time.


Specific policies regarding:


Appointment scheduling and cancellations


No-show or late cancellation fees


Insurance coverage and out-of-pocket costs


Membership plans and aesthetic packages


may be provided separately in writing, in-office, or through patient forms. In the event of a conflict, the written policies you sign or receive at the time of service will govern.


8. Intellectual Property


All content on this website— including text, graphics, logos, images, videos, and other materials—is owned by or licensed to MidSouth and is protected by copyright, trademark, and other intellectual property laws.


You may view, download, or print reasonable portions of the website content for your personal, non-commercial use only. You may not modify, reproduce, distribute, publish, or create derivative works from the website content without our prior written consent.


9. Third-Party Links and Services


Our website may contain links to third-party websites, services, or resources that are not controlled by MidSouth. These links are provided for your convenience only.


We are not responsible for the content, privacy practices, or terms of any third-party websites or services. Accessing any third-party website is at your own risk and subject to that site’s own terms and policies.


10. Disclaimer of Warranties


Your use of this website is at your sole risk. The website and all content are provided on an “as is” and “as available” basis.


To the fullest extent permitted by law, we disclaim all warranties of any kind, whether express or implied, including but not limited to implied warranties of merchantability, fitness for a particular purpose, title, and non-infringement.


We do not warrant that:


The website will be uninterrupted, error-free, secure, or available at all times; or


The information on the website is always current, complete, or free of typographical errors.


11. Limitation of Liability


To the fullest extent permitted by law, MidSouth and its owners, providers, employees, and affiliates shall not be liable for any indirect, incidental, special, consequential, or punitive damages arising out of or related to your use of (or inability to use) the website, even if we have been advised of the possibility of such damages.


In no event shall our total liability to you for any claims related to the website exceed the amount, if any, that you paid (if anything) for access to the website.


Some jurisdictions do not allow limitations of certain damages, so some of the above limitations may not apply to you.


12. Indemnification


You agree to indemnify, defend, and hold harmless MidSouth and its owners, providers, employees, and affiliates from and against any and all claims, liabilities, damages, losses, and expenses (including reasonable attorneys’ fees) arising out of or related to:


Your use of the website;


Your violation of these Terms; or


Your violation of any rights of another person or entity.


13. Changes to the Website and These Terms


We may update, modify, or discontinue any part of the website at any time without notice.


We may also revise these Terms from time to time. When we do, we will update the “Last updated” date above. Your continued use of the website after changes are posted constitutes your acceptance of the revised Terms.


14. Governing Law


These Terms and your use of the website shall be governed by and construed in accordance with the laws of the State of [Insert State], without regard to its conflict of law principles.


15. Contact Us


If you have questions about these Terms, our communications practices (including SMS), or how your information is used, please contact us:


MidSouth Integrative Medical

1973 Oak Tree Cv.

Hernando, MS 38632

7651 Tchulahoma Rd.

Southaven, MS 38671

Phone: 662-349-0980

Email: msintegrative@gmail.com

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