Prac%cing and Thriving in an Unlicensed State
|
|
|
- Isabel Wilson
- 5 years ago
- Views:
Transcription
1 Prac%cing and Thriving in an Unlicensed State
2 WHY? What can you do? How do you prac%ce? Don t you want to be in a licensed state?
3 Naturo- what?? FEAR...the discouraging factor Legal Ramifica%ons Disregard
4 Objec%ves Discuss various ways to set up a prac%ce in an unlicensed state. Learn prac%cal and legal %ps regarding marke%ng strategies. Learn ways to develop referral networks and working rela%onships with licensed prac%%oners in the community. Discuss various legal methods to obtain lab work.
5 Objec%ves cont d Iden%fy specific supplements that can omen be used in place of prescribed medica%ons. Discuss various ways to help pa%ents obtain the medicines necessary for their wellbeing. Learn prac%cal and mo%va%onal ways for garnering respect and recogni%on as a naturopathic doctor in his or her community. Gain a clear understanding of the benefits of prac%cing with limita%ons
6 LEGAL ISSUES PRACTICAL ISSUES
7 What are your prac%ce op%ons? Solo prac%ce Mul%- prac%%oner
8 C L I N I C
9 Independent contractor? Employee? Behavioral control Financial control Rela%onship
10 An3- Kickback Statute a criminal statute that prohibits the exchange (or offer to exchange), of anything of value, in an effort to induce (or reward) the referral of federal health care program business.
11 Website Social Media Marke%ng Methods
12 the op3ons are endless
13
14 Social Media Website Print Marke%ng Methods
15 Pa%ent Doctor Treat Medicine Naturopathic
16 Client Health Coach Support Naturopathy
17 Social Media Website Print Marke%ng Methods Public Speaking Other Networking
18
19 Oconee Natural Healthcare 1612 Mars Hill Road Suite C. Watkinsville, Georgia Please print registra%on informa%on. Thank you. Today s date: First name Middle Name Last Name (please circle the name you go by or indicate if you have a nickname) Phone # s: home: work mobile Street address: City: State: Zip code: Sex: Age: Birth date: Occupa%on: Employer name: Who is financially responsible for this account? Spouse/partner s name: phone #: Emergency contact: name: phone #: se/partner sname: phone #: My general prac%%oner is: mergency contact: name: phone #: My general prac%%oner is: ******************* I understand that although naturopathic physicians are licensed health care providers in many states, they are not currently licensed in Georgia and that any naturopathic therapies or modali%es ******************* recommended by Dr. Hecht are not meant to replace conven%onal treatments prescribed by my M.D. I understand that naturopathic physicians are not covered by insurance companies in Georgia and that all payments are due at the %me of services rendered. I understand that if I do not cancel an appointment with 24 hour no%ce I will be charged the full cost for the appointment. Pa%ent or guardian s signature In the space below please tell me how you found out about my prac@ce and if you were referred by someone. Thank you.
20 Neurologist Acupuncturist Periodon%st Oncologist General prac%%oner Massage therapist Physical therapist Internist
21 Who are you? What are your creden%als? What can you offer specifically? (Case Studies) Contact info!
22 Join or form a local organiza@on of health prac@@oners
23 Prac%cing and thriving despite limita%ons
24 WHAT ABOUT LAB WORK!
25 Online laboratory tes%ng Func%onal lab tests (mail- in test kits) County health department
26 Be ready for results!
27 Dietary Supplement
28 Hormones and Ac%ve Glandulars
29 How do you effec%vely refer a pa%ent back to his/her GP with recommended lab work and/or medica%ons?
30 Jane Doe, ND
31 Respeciul Listening Confidence Humility Integrity
32 Medicine for when the lights go out
33
34
35
36 Thank you! Wyler Hecht, N.D., L.Ac.
Recrea&onal Therapy. Thomas K. Skalko, Ph.D., LRT/CTRS Chair, Commi<ee on Accredita&on of Recrea&onal Therapy Educa&on
Recrea&onal Therapy Thomas K. Skalko, Ph.D., LRT/CTRS Chair, Commi
CONTINUUM CHIROPRACTIC ADULT HEALTH HISTORY FORM
CONTINUUM CHIROPRACTIC ADULT HEALTH HISTORY FORM Today s Date PERSONAL DATA Legal Name Preferred Name Age Date of Birth Height Weight Home Address City State Zip Home phone ( ) Business Phone ( ) Cell
Create More Effec,ve Doctor Appointments. More than 100,ps you can start using today! By: Shani Weber, M.S.
Create More Effec,ve Doctor Appointments More than 100,ps you can start using today! By: Shani Weber, M.S. How Do You Get the Help You Need? Build a great medical team Have reasonable expecta6ons Collect
arah s CLIENT INFORMATION M A S S A G E T H E R A P Y
1 arah s M A S S A G E T H E R A P Y CLIENT INFORMATION Please take care to fill out this form thoroughly and carefully. The information will help your massage therapist provide optimal care. Your cooperation
Our office is located at 2030 Drew Street, Clearwater FL, We are on Drew Street, in between N.E Old Coachman Road and Hercules Avenue.
Dear New Patient, Thank you for choosing Dennis M. Lox, M.D to participate in your healthcare. We realize that you could have chosen any other office, so we are honored that you have chosen us. While Dr.
GENERAL INFORMATION. Name: Date of Birth: First Name M.I Last Name MM/DD/YYYY. Age: Sex: F M Phone Number: Emergency Contact: Relationship to patient:
New Patinet Form for Acupuncture Treatment GENERAL INFORMATION Name: Date of Birth: First Name M.I Last Name MM/DD/YYYY Age: Sex: F M Phone Number: Email: Cell Number: Emergency Contact: Relationship to
APPLICATION TO EMPLOY A
STATE OF CALIFORNIA - STATE AND CONSUMER SERVICES AGENCY ARNOLD SCHWARZENEGGER, Governor BOARD OF PSYCHOLOGY 2005 Evergreen Street, SUITE 1400 SACRAMENTO, CA 95815-3831 (916) 263-2699 ext. 3303 www.psychboard.ca.gov
International Travel Medical Questionnaire
International Travel Medical Questionnaire Name: of Birth: Gender: M/F Last First Month/Day/Year Circle One Address: Street City, State Zip Daytime Phone: Evening Phone: Primary care physician: Emergency
Training Application for
STRENGTH Rx REAL TRAINING NO GIMMICKS HARD WORK REAL RESULTS Training Application for STRENGTH Rx Welcome to STRENGTH Rx. We offer Strength & Conditioning training for all athletes looking to improve all
Oncology Care Model Overview
Oncology Care Model Overview Centers for Medicare & Medicaid Services Innova3on Center (CMMI) September 2017 Innova3on at CMS Center for Medicare & Medicaid Innova3on (Innova3on Center) Established by
Chapel Hill Pediatric Dentistry
Chapel Hill Pediatric Dentistry Avni C. Rampersaud, D.D.S., P.A. 919.929.0489 I. General Information Date: / / Patient: Last First Middle Child s Preferred Name: Sex (please circle): Male Female Age: Date
Insurance Information Release Form
Insurance Information Release Form Policy Holder s Information Policy Holder s Name Birthday Social Security Number Spouses Name Birthday Social Security Number Dependent's Name (last name if different
th Street Urbandale, IA YOST
YfC 3993 100th Street Urbandale, IA 50322 515.278.YOST www.yostfamilychiropractic.com Demographics: Language (Primary) Race: Unspecified American Indian or Alaska Native Black or African American Other
Chiropractic for pediatric development and adult health
Raleigh Specific Chiropractic Chiropractic for pediatric development and adult health 7721 Six Forks Rd. Suite 138 Raleigh, NC 27615 (919) 846-7004 Items to bring to your first visit: All new patient paperwork
APPLICATION FOR SERVICES
APPLICATION FOR SERVICES CLIENT - PERSONAL INFORMATION First Name M.I. Last Name Today s Street Address City State Zip Birth date Home phone (ok to leave msg? Y - N) Cell phone (ok to leave msg? Y - N
HEALING HANDS CHIROPRACTIC, LLC 3 Hall Ave Wallingford, CT healinghandsdc.com
HEALING HANDS CHIROPRACTIC, LLC 3 Hall Ave Wallingford, CT 06492 203-626-9994 healinghandsdc.com Child Intake Form PERSONAL INFORMATION Date Child s Name: Address Gender M F Age Birthdate City State Zip
Center for Autism and Related Disabilities (CARD) Providing Support and Assistance to Optimize Potential
Center for Autism and Related Disabilities (CARD) Providing Support and Assistance to Optimize Potential Hello, Thank you for your referral to the Center for Autism and Related Disabilities (CARD). CARD
LUCAS CHIROPRACTIC 903 Howard St. Walla Walla WA PATIENT INTAKE - update
LUCAS CHIROPRACTIC 903 Howard St. Walla Walla WA 99362 PATIENT INTAKE - update Name Today s Date / / Date of Birth / / Address City State Zip Please check box for preferred communication means E-Mail Home
New Client Reformer Session Packet
New Client Reformer Session Packet Welcome and thank you for your interest in the Pilates Reformer program with University Recreation. You are taking the first steps towards improved health and wellness.
Address (if different from above):
Lee H. Baker, DDS 1243 Augusta West Pkwy Augusta, GA 30909 (706) 855-8989-Phone (706) 855-0321-Fax www.drleebaker.com Welcome to our practice! In order to know you and your child better, please complete
Sound Naturopathic Clinic Front Street, Suite 103 Poulsbo, WA (360) (Phone) (360) (Fax)
Sound Naturopathic Clinic 20270 Front Street, Suite 103 Poulsbo, WA 98370 (360) 598-6999 (Phone) (360) 598-2104 (Fax) Welcome to Sound Naturopathic Clinic! Please fill out all (6 pages) of the following
Fertility Specialty Care
Fertility Specialty Care PATIENT INFORMATION: Last Name First Name & Initial Address City State Zip Home Phone ( ) Cell Phone ( ) Date of Birth Social Security Number Marital Status: Married Single Ethnicity:
ADULT INTAKE QUESTIONNAIRE. Ok to leave message? Yes No. Present psychological difficulties please check any that apply to you at this time.
ADULT INTAKE QUESTIONNAIRE Name: Today s Date: Age: Date of Birth: Address: Home phone: Work phone: Cell phone: Ok to leave message? Yes No Ok to leave message? Yes No Ok to leave message? Yes No Email:
2018 Conference on Ending Homelessness. Informa(onal Session Proposal Webinar
2018 Conference on Ending Homelessness Informa(onal Session Proposal Webinar Welcome To The Webinar Thank you for joining today s webinar! All par:cipants will be muted during the webinar to ensure good
Moms Help Organization Helping Moms to be the best Moms they can be! West Sample Road, #24 Coral Springs, FL
Moms Help Organization Helping Moms to be the best Moms they can be! 11471 West Sample Road, #24 Coral Springs, FL 33065 www.momshelp.org Application for Assistance Welcome to the Moms Help Organization.
Lifestyle for Health 993 Greenland Forest Drive Monument, CO
Lifestyle for Health 993 Greenland Forest Drive Monument, CO 80132 719-488-5688 www.cheryltownsley.com info@lifestyleforhealth.com Initial Health Consultation New Client Form and Release Form Please complete
Ethical Guidelines 9/24/15. Controlled Substance Update Texas Nurse Prac66oners Annual Conference Objec6ves
Texas Nurse Prac66oners Annual Conference 2015 Kimberly H. Oas, MSN, APRN, FNP- BC Jan Zdanuk, DNP, APRN, FNP- BC, FAANP Ethical Guidelines Speakers report no rela6onships with business or industry that
PLEASE PRINT PLEASE CHECK THE BOX AFTER THE PHONE NUMBER THAT YOU WANT AS YOUR PREFERRED NUMBER
NORTHERN VIRGINIA CENTER FOR ARTHRITIS PLEASE PRINT PATIENT REGISTRATION Patient s Name: DOB: Sex: Address: PLEASE CHECK THE BOX AFTER THE PHONE NUMBER THAT YOU WANT AS YOUR PREFERRED NUMBER Home#( ) [
Client Intake Form Therapeutic Massage
Personal Information: Client Intake Form Therapeutic Massage Name Phone (Day) Phone (Eve) Address City/State/Zip email Date of Birth Occupation Emergency Contact Phone The following information will be
NEW PATIENT PAPERWORK
NEW PATIENT PAPERWORK Welcome! Please fill out the necessary paperwork provided. It is our pleasure to serve you and your family. How did you find out about us? If It was a friend or doctor, please list
MEETING PEOPLE WHERE THEY ARE
Advancing the Concept of Stages of Change & Treatment for Individuals with Co- Occurring Disorders MEETING PEOPLE WHERE THEY ARE Presented by Erwin Concepcion, Ph.D. LP 1 Objec,ves 1. Describe one primary
Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
![Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No](/thumbs/89/99616722.jpg "Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No")
Patient Information Welcome Who is responsible for this account? SSN Relationship to Patient Patient Name Insurance Co. Name: Preferred First Name Group #: ID #: Sex [ ] M [ ] F Age: Birthdate SS# Birthdate
PATIENT INTRODUCTION. Name Date. Street Address. State Zip Code. Mailing Address. City State Zip Code. Home Phone ( ) Work Phone ( ) address
Austin Naturopathic Medicine Dr. Louisa L. Williams tel. 512-600.6983 fax: 512-628-0608 www.austinnaturopathicmedicine.com PATIENT INTRODUCTION Name Date Street Address City State Zip Code Mailing Address
Liberty Chiropractic Clinic Scarsdale Blvd., Houston, TX
Liberty Chiropractic Clinic, -6154 Patient's Name Patient's Address City State Zip Code Age D.O.B. Single Married Divorced Widowed No. of children Occupation Employer Home Phone Work Phone Cell Phone Email
Jumpstart, Fitness Assessment, & Body Composition
Jumpstart, Fitness Assessment, & Body Composition Waiver, Release and Hold Harmless Agreement In consideration of permission granted by Purdue University allowing me to participate in Personal Training
Massage Office Policies
Massage Office Policies 1. All appointments are scheduled in advance. 2. Clients are expected to pay for all services at the time they are rendered. We accept cash and debit/credit cards for payment. 3.
Natural Health Center
Natural Health Center 420 Yucca Lane - Turpin, OK 73950 Tel. No. (580) 778-3310 / Cell No. (620) 391-5520 / Fax No. (580) 778-3340 Today s Date / / Application for Treatment Name: Birthdate: SS# Address:
A practical guide to living with and after cancer. Helping you take an active role in your cancer care
A practical guide to living with and after cancer Helping you take an active role in your cancer care About this leaflet About this leaflet 2 This leaflet is about how you can take an active role in your
Client Intake Form - Therapeutic Massage
Client Intake Form - Therapeutic Massage Personal Information: Date: Name: Phone #: Address: City/State/Zip: Email: DOB: Occupation: Emergency Contact: Phone #: HOW DID YOU HEAR ABOUT US? The following
New Patient Information
Patient's Street Address: Home Phone: Cell Phone: of Birth: / / New Patient Information State: Name of Person Responsible for This Account: E-Mail Address: Zip Code: Work Phone: SSN: Do You Have Dental
CHIROPRACTIC NEW PATIENT FORM REASON FOR VISIT
FULL NAME: DATE OF BIRTH (DD/MM/YYYY): STREET ADDRESS: PROVINCE: HOME PHONE: (CHECK WHICH PREFERRED) WORK PHONE: EMAIL ADDRESS: NEW LEGISLATION REQUIRES THAT WE OBTAIN CONSENT PRIOR TO SENDING EMAILS TO
Acknowledgment of Clinic Terms
Acknowledgment of Clinic Terms Our GOAL The goal of CHIRO-FIT, Inc. is to detect and correct subluxations of the spine and body. We do not focus on the treatment of pain and disease, instead aim to help
NC Hair Loss Center 1418 Aversboro Rd Suite 103 Garner, NC Phone
NC Hair Loss Center 1418 Aversboro Rd Suite 103 Garner, NC 27529 Phone 919-771-5430 Email: service@nchairlosscenter.com Consent to Use or Disclose Information for Treatment, Payment, Health Care Operations,
Tomorrow s SMILES Program
Do you know a promising teen whose future is at-risk due to lack of dental treatment? Would your teen and his or her family understand, appreciate, and value pro-bono dental care? If so, your teen may
Chapel Hill Pediatric Dentistry
Chapel Hill Pediatric Dentistry Avni C. Rampersaud, D.D.S., P.A. Yvette E. Thompson, D.D.S. 919.929.0489 I. General Information Date: / / Patient: Last First Middle Child s Preferred Name: Sex (please
Welcome to Saratoga Ophthalmology!
Amjad M. Hammad, MD, MBA Salman J. Yousuf, DO The Center for Vitreo-Retinal Surgery Charles H. Rheeman, MD Gregory B. Krohel, MD The Center for Oculoplastics & Neuro-Ophthalmology Kamran I. Chaudhri, MD
Name: D.O.B. Address: City: ST: Zip: OccupaDon: How did you hear about us:
Office Use Only! Filed: Mailed:! Name: D.O.B. Address: City: ST: Zip: Phone: (Best #) E-mail: OccupaDon: How did you hear about us: PLEASE READ THE FOLLOWING AND SIGN BELOW: Thermography Rio Grande Valley
NEW PATIENT PACKET Welcome To Our Clinic!
NEW PATIENT PACKET Welcome To Our Clinic! Name: Date: Address: City: State: Zip Code: Shipping address: Home phone: ( ) - Cell phone: ( ) - E-mail: Date of Birth: Age: Gender: F / M / MTF / FTM Height:
Application Packet. The Application for Funds must be complete and submitted by the due date in order to be considered.
2018 Grant Schedule: Applications Due May 2, 2018 Grants Awarded May 18, 2018 Applications Due October 24, 2018 Grants Awarded November 9, 2018 Application Packet The Application for Funds must be complete
SonoMarin Neurofeedback Eileen Roberts PhD
SonoMarin Neurofeedback Eileen Roberts PhD 707.338.9084 drrobs@hotmail.com Patient Information Name: Social Security #: Address: Home Telephone: City: Zip: Cell Phone: Date of Birth: Marital Status: Spouse/Parent
Address City State Zip Code
Name Cell Phone Address City State Zip Code Date of Birth / / Male/Female Age Email SS# Number of Children Name of Children Employer Type of Work Marital Status Married Single Divorced Separated Widowed
Patient Name: Male or Female DOB: Patient Address: City/State/Zip: Patient Phone Number: Primary Policy holder: Relationship: DOB:
Fax to: 972-393-4200 Email to: denise@points4health.com Points of Health & Herbal Medicine Denise Edmiston, L.Ac., LCSW 413 W. Bethel Rd., Suite 202 Coppell, Texas 75019 P-(972)506-8113 F(972)393-4200
Massachusetts Certified Peer Specialist Training Application Packet
Packet This packet includes everything you will need to apply for the Massachusetts Certified Peer Training Program. There are several steps to this process which are clearly outlined in the Instructions,
Pro Active Physical Therapy & Sports Medicine
Pro Active Physical Therapy & Sports Medicine Consent and Statement of Financial Responsibility 1. CONSENT FOR TREATMENT: I consent to and authorize my physical therapist, occupational therapist and other
Center for Natural Healing
Center for Natural Healing 225 610 3447 or 225 927 9273 Name Date Occupation Birth Height Weight List your top three health concerns that you would like to address naturally 1. 2. 3. Regarding the health
Windrose Naturopathic Clinic Family Practice Preventative Care 1137 W Garland Ave, Spokane WA (509) (509) (fax)
NEW PEDIATRIC PATIENT INFORMATION Date: To be filled out by parent or guardian: Child s Name: Age: DoB: Height: Weight: Address: City, State, Zip Male Female Parent / Guardian Information: Name: Phone:
Lake Psychological Services, LLC
Lake Psychological Services, LLC Welcome to Lake Psychological Services and thanks for choosing our office for your health care needs. Seeking treatment is not an easy decision and you may have questions
GARDEN STATE SLEEP CENTER REGISTRATION FORM PATIENT INFORMATION:
GARDEN STATE SLEEP CENTER REGISTRATION FORM (Please Print) Today s Date: Primary Care Physician: PATIENT INFORMATION: Last Name: First: Middle: Mr. Miss Dr. Mrs. Ms. Marital Status (Please check one) Single
Baa Hózhó Navajo Prep Math Summer Camp 2017
Math Summer Camp 2017 Application Packet Grades 7-12 May 30-June 3, 2017 Navajo Preparatory School, Farmington, NM Residential Camp Application Checklist A complete application must include the following:
Extended Health Care Company Do you need any help retaining information about your health insurance coverage? Yes No
PATIENT ENTRANCE FORM Date Circle: Male Female Name Birth Date (dd/mm/yy) Age Address Apt # City Province Postal Code Home # Cell # Work # E-MAIL Occupation Employer Name of Emergency Contact Contact #
CHIROPRACTIC NEW PATIENT FORM REASON FOR VISIT
DR. ANN IZARD, B.COMM, DC DOCTOR OF CHIROPRACTIC 4353 HASTINGS STREET BURNABY, BC V5C 2J7 TEL: 604.293.2941 FAX: 604.298.2941 WWW.BHIHC.COM WWW.ANNIZARD.COM FULL NAME: DATE OF BIRTH (DD/MM/YYYY): STREET
Dear Prospective Volunteers,
Operated by Heritage Christian Services PO Box 200 Webster, NY 14580 585-872-2540 Fax: 585-872-4847 www.heritagechristianstables.org Dear Prospective Volunteers, Heritage Christian Stables Therapeutic
Get Acquainted Questionnaire Tell Us About Your Child!
Get Acquainted Questionnaire Tell Us About Your Child! Today s Date Child s First Name Child s Last Name Nickname M F Child s Age Child s Date of Birth / / Residence Address City State Zip Residence Phone
Guide to Tobacco Incentives. Tools to Implement a Policy at Your Organization
Tools to Implement a Policy at Your Organization Contents Introduction... Sample Tobacco Surcharge Policy... Sample Non-Tobacco User Discount Policy... Definition of a Tobacco User... Sample Tobacco Use
RAINIER VALLEY CHIROPRACTIC P.S th Avenue S. Seattle, WA 98118
Patient Health History Full Name Date Street Address City & State Zip Phone Number Gender Date of Birth Age SSN How did you hear about our office? Marital Status # of Children? Currently Pregnant? / How
APPLICATION FOR ADMISSION (PLEASE PRINT CLEARLY)
1317 w. Washington Blvd. Fort Wayne, In. 46802 260-424-2341 APPLICATION FOR ADMISSION (PLEASE PRINT CLEARLY) NAME: _ FIRST MI LAST DATE OF BIRTH: / / AGE: SOCIAL SECURITY NUMBER: LAST OR CURRENT ADDRESS:
INNOVA Medical and Rehab Dr. Farhad Babakhani. BSc, DC, FCCRS, RAc # Elgin Mills Road East Richmond Hill, ON L4S 0B2
INNOVA Medical and Rehab Dr. Farhad Babakhani. BSc, DC, FCCRS, RAc #111-1650 Elgin Mills Road East Richmond Hill, ON L4S 0B2 Tel: (905) 884-2121 Fax: (905) 884-8845 PATIENT INFORMATION: Name: Address:
New Patient Intake Form
New Patient Intake Form Name: Address: Date: Birth Date: / / City: State: Zip SS#: - - Male Female Single Married Divorced Widowed I give The Center for Spine, Sport and Physical Medicine permission to
Acknowledgement of receipt of notice of privacy practices
Acknowledgement of receipt of notice of privacy practices NOTICE OF PRIVACY PRACTICES I acknowledge that I have received a Notice of Privacy Practices from Kettering Physician Network (dba Kettering Cancer
Patient Registration Form
Patient Registration Form Date: Last Name: First: Middle: Street Address City State Zip Home Phone: Work Phone: Mobile Phone: Date of Birth: Social Security: Sex: Male Female Martial Status: Single Married
Nutrigenetics and Nutrigenomics in Clinical Research and Practice
Nutrigenetics and Nutrigenomics in Clinical Research and Practice Mar$n Kohlmeier, MD, PhD University of North Carolina at Chapel Hill Department of Nutri7on and UNC Nutri7on Research Ins7tute mkohlmeier@unc.edu
Baby-Sitting - $20 Per Day/Per Nanny (local clients) Less than 24 hours notice $30 Per Day/Per Nanny. Hotel Overnight Sitting - $35 per Day/Per Nanny
ALL ABOUT NANNIES BUSINESS PHONE: 602-266-9116 BUSINESS FACSIMILE: 602-266-9787 BUSINESS EMAIL: ADMIN@ALLABOUTNANNIESINC.COM TEMPORARY, BABY-SITTING, HOTEL & ON-CALL AS NEEDED Mother s Full Name: Place
Medications. New Patient Registration. Billing and Insurance. Phone Calls. Prescription Refills. Lab Results and Test Results
Dear New Patient: We would like to welcome you to our practice. Our goal is to make your experience with us as pleasant as possible. In order to help us meet this goal we have listed some helpful hints
Integrated Mindfulness Interven1on
Integrated Mindfulness Interven1on Elizabeth Berlasso, NSRCT, Psychotherapist Rob Dickson, Clinical Team Leader Tara Sampalli, PhD, Manager Minakshi Dhir, Research Associate Integrated Chronic Care Service,
Tell Us About Your Child
5C Medical Park Drive Pomona, NY 10970 (845) 414-9626 drsmith@smithslittlesmiles.com www.smithslittlesmiles.com Marita Smith, DDS Board Certified Pediatric Dentistry We are thrilled to welcome you and
Adult Fluency Case History Form
Adult Fluency Case History Form Name: Address: Phone: Primary Language: Referred By: Primary Doctor: Phone: Age: Date of Birth: Please describe your speech: What information do you hope to obtain from
Revitalize, Regenerate & Restore Office of Dr. Kashi Rai. Health Coaching Packet
1 Health Coaching Packet A health coach is knowledgeable in the process of health behavior modification. We work in partnership with our clients to assist them to enhance personal accountability, set goals
Client Name: Date of Birth: Address: City: Zip code: Hm #: ( ) -. Cell#: ( ) -. Wrk#: ( ) -. Otr#: ( ) -.
New Client Intake Date: Client Name: Date of Birth: Address: City: Zip code: Hm #: ( ) -. Cell#: ( ) -. Wrk#: ( ) -. Otr#: ( ) -. Employer Email: Emergency Contact Name Relationship Phone number TREATMENT
BOTHELL INTEGRATED HEALTH, LLC Therapeutic Massage
BOTHELL INTEGRATED HEALTH, LLC Therapeutic Massage Patient Name Date Address City State Zip Phone (home) (cell) Emergency Contact Name Phone Employer Date of Birth Work Phone Social Security # Is condition
JACKSONVILLE SPEECH & HEARING CENTER PATIENT INFORMATION FORM PEDIATRIC (CHILD) - AUDIOLOGY Please Print
JACKSONVILLE SPEECH & HEARING CENTER PATIENT INFORMATION FORM PEDIATRIC (CHILD) - AUDIOLOGY Please Print Referring Physician: Child s (Patient) Name: LAST FIRST MIDDLE Gender: Male Female Date of Birth:
EXAMPLE ABSTRACT REASONING. Medicine and Abstract Reasoning - Example 1. One 2 One Medicine UKCAT Preparation Day
ABSTRACT REASONING Medicine and Abstract Reasoning - Example 1. The similari+es and subtle differences between biochemical structures is the bases of pharmacology - the study of medica+ons. Below we see
Dr. Janet L. Yarger 510 Baxter Road, Suite 8, Chesterfield, MO
Registration Form Date: / / Name: Social Security #: - - Address: City: State: Zip Code: Home Phone #: ( ) - Age: Date of Birth / / Cell Phone #: ( ) - Best Phone to call you at: HOME/CELL/WORK Email Address:
FREQUENTLY ASKED QUESTIONS ABOUT MENTAL HEALTH ADVANCE DIRECTIVES GUIDE FOR CONSUMERS
(800) 692-7443 (Voice) (877) 375-7139 (TDD) www.disabilityrightspa.org FREQUENTLY ASKED QUESTIONS ABOUT MENTAL HEALTH ADVANCE DIRECTIVES GUIDE FOR CONSUMERS What is a Mental Health Advance Directive? A
The Dale Association s Peer Specialist Program
The Dale Association s Peer Specialist Program What kind of services does the program offer? Job description: provide and oversee supportive services through consultations and linkages to persons diagnosed
Registration Form Women s Health Initiative
YWCA WHI 1500 14 th St. Lubbock, Texas 79401 Phone: (806) 687-8858 Fax: (806) 784-0698 1 Registration Form Women s Health Initiative Date: Name (Last, First, middle, Maiden) Age: Date of Birth SS # Mailing
Corner on Wellness Chiropractic Center Therapeutic Massage
Corner on Wellness Chiropractic Center Therapeutic Massage Patient Name Date Address _ City State Zip Phone Email Emergency Contact Name Phone Employer Work Phone Date of Birth Social Security # Is condition
Patient Demographics
M.D. INFO INSURANCE INFO PATIENT INFORMATION Patient's Name (Last, First, Middle Initial): Patient Demographics Patient's Address: City: Phone #: Home: Cell: Work: State: Zip Code: Patient Date of Birth
SUZANNE CLEGG RDN, LAc
SUZANNE CLEGG RDN, LAc Client Informed Consent and Disclosure Statement For Office Sessions Thank you for your interest in working with me as a client. I am providing you with the following information
Transitional Housing Application
Transitional Housing Application Applicant Information Name: Date of birth: SSN: ID Number: Current address: City: State: ZIP Code: Phone: Email: Name of Last Social Worker or Probation Officer:: Original
New Patient Paperwork
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
Paent Parcipaon Group Report 2013/14
Paent Parcipaon Group Report 2013/14 Vassall Medical Centre is a partnership practice which presently comprises two partners and three salaried GP s with three practice nurses. As well as face to face
Name Preferred Name. Date of Birth / / Gender: Male Female Other. SSN - - Preferred Phone Other Phone. Street Address. City State Zip Code
New Patient Information Name Preferred Name last first mi Date of Birth / / Gender: Male Female Other SSN - - Preferred Phone Other Phone Email Address Street Address City State Zip Code Employment Full
Completed applications can be submitted either by mail or to:
Dear Sir or Madam: Thank you for your interest in the Feldenkrais Foundation s Low Fee Clinic. This popular clinic provides individual Feldenkrais Functional Integration sessions at a reduced rate for
SmileNet SM Dental Discount Program
SmileNet SM Dental Discount Program We want to catch you smiling. for Individuals and Families Effective April 1, 2005 Why Dental Care Should Be a Priority for You and Your Family Good oral health means
Evaluation of Vestibular (Balance) Disorders
Evaluation of Vestibular (Balance) Disorders HEARING TEST: Because both hearing and balance end organs are located in your inner ear, it is important to evaluate your hearing. If you have a hearing loss,
GRASP Graded Repe,,ve Arm Supplementary Program. Janice Eng, PhD, BSc(PT/OT) Dept of Physical Therapy University of BC GF Strong Rehab Centre
GRASP Graded Repe,,ve Arm Supplementary Program Janice Eng, PhD, BSc(PT/OT) Dept of Physical Therapy University of BC GF Strong Rehab Centre What is GRASP? GRASP Graded repe,,ve arm supplementary program
APPLICATION FOR AL ANON MEMBER INVOLVED IN ALATEEN SERVICE (AMIAS)
Al Anon Family Groups Florida South (Area 10), Inc. hereafter referred to as AFG Florida South APPLICATION FOR AL ANON MEMBER INVOLVED IN ALATEEN SERVICE (AMIAS) This information will only be used in accordance
MEMBER GRIEVANCE/COMPLAINT FORM. Address City State Zip Code
MEMBER GRIEVANCE/COMPLAINT FORM Date: Please print all information. Complainant information: ( ) ( ) Name Work Telephone Number Home Telephone Number Address City State Zip Code Name of person(s) related
Gait Analysis Client Intake Form
Gait Analysis Client Intake Form Date: / / Welcome to the clinic! Please complete the following questionnaire. Your answers will help us better analyze your gait data. PERSONAL INFORMATION Name :_ last
Massage Client Intake Form
Massage Client Intake Form Date: Name: Male Female DOB: Address: City: State: Zip: Phone: Can a message be left at this number? Yes No Occupation: Hobbies/Sports/Most frequent activities: What is the goal