Idaho Naturopathic Medicine 6550 W Emerald, Ste 112 Boise, Idaho Ph: Fax:
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1 Idah Naturpathic Medicine 6550 W Emerald, Ste 112 Bise, Idah Ph: Fax: Welcme t Idah Naturpathic Medicine We lk frward t meeting yu sn. It is ur desire t prvide yu quality service and pprtunities t enjy wellness. Please read the fllwing s yu understand ur plicies and csts. Office hurs. 9:30 am -5:00 pm Mnday-Thursday. T make yur initial visit prductive, please see the fllwing directins: Enclsed is the Intake frm. Please cmplete and bring t yur upcming visit. Please bring all supplements and medicatins yu currently take. Please bring them in their riginal bttles. Idah Naturpathic Medicine is Fragrance Free. Please refrain frm wearing perfume, aftershave, clgne, ltin, dedrant, hair spray r any ther fragranced prduct that may be perceptible t thers. We thank yu fr this cnsideratin f ur staff and patients health. Patients wh cme t the clinic wearing perceptible fragrance may be asked t reschedule their appintments. Friends r family wearing fragrance and accmpanying patients may be requested t wait utside the ffice during a visit. Initial: I understand the fragrance free plicy and agree nt t wear fragrance t the ffice f Idah Naturpathic Medicine. Supplement rders: Please allw 24 hurs ntice fr filling supplement rders. Orders may be requested by phne r idnatmed@gmail.cm If paying by credit card, a credit card number may be left n file; please remind ur ffice t bill yur credit card n file at the time f the supplement rder. Initial: I understand the 24-hur advanced ntice supplement rder plicy: Insurance. Mst insurance cmpanies d nt reimburse fr naturpathic care. Hwever, a few d; cntact yur insurance cmpany prir t the visit t determine if yu can seek reimbursement. Yu will be given a frm with visit and diagnsis cdes t facilitate filing with yur insurance cmpany. Sme lab wrk may be reimbursed, such as cmmn bld tests, but many specialty labs may nt qualify fr reimbursement. Idah Naturpathic Medicine Plicy Frm Page 1
2 Financial Plicy and Csts Payment is expected at time f visit. Payment ptins: cash, check, credit cards Visa/MasterCard Naturpathic Appintments Initial adult, 2-hur: $205 The first adult fllw-up is usually 45 minutes: $95 Subsequent visits are usually 30 minutes: $80 Initial pediatric visit, children under 13 years ld, 1 hur: $140 Pediatric fllw-up visits are usually 30 minutes: $80 Acupuncture visits. Initial visit 90 minutes: $90 Fllw up visits 1 hur: $75 Allergy Desensitizatin (NAET) Initial visit 90 minutes: $130 Fllw up visits minutes: $65 Missed Appintment Charges In respect t ur time and ther patients wh may want t schedule, we request that patients cntact us if they need t cancel r reschedule their appintments. We understand that life happens and that yu may need t cancel r reschedule; we are happy t reschedule yur visit at yur cnvenience with apprpriate ntice. Please cntact us 1 full business day (24 hurs) befre yur appintment if yu wish t cancel r reschedule yur appintment. A missed appintment fee f $50 will be charged fr a missed fllw-up appintment withut 1 full business day (24-hur) ntice. A missed appintment fee f $100 will be charged fr a missed appintment fr new patient visits withut 1 full business day (24-hur) ntice. Initial: I understand that I may be charged a missed appintment fee if I d nt ntify Idah Naturpathic Medicine 1 full business day (24-hur) in advance f changing r canceling an appintment. I have read, understand, and agree t the abve infrmatin. Patient Name (print) Date: _ Signature: Signature f respnsible party, parent, r guardian. Idah Naturpathic Medicine Plicy Frm Page 2
3 Idah Naturpathic Medicine 6550 W Emerald, Ste 112 Bise, Idah Ph: Fax: PEDIATRIC PATIENT INTAKE FORM PERSONAL INFORMATION Tday s Date Child s Name Age Date f Birth Gender Mther s Name Father s Name Child lives with Mailing Address City State Zip Address f ther parent (if different frm abve) Mther s phne (hme) (wrk) (cell) Father s phne (hme) (wrk) (cell) Current schl Grade Hw did yu hear abut ur clinic? MEDICAL HISTORY List current health cncerns in rder f imprtance: List all prescriptin medicatins, nutritinal supplements, herbs, r hmepathic remedies currently being taken. Please list dses if knwn. Please list any medicatins, natural r prescriptin, yur child has taken in the past: Allergy t any medicines, if s what? List past surgeries r hspitalizatins. Please list age. Idah Naturpathic Medicine Pediatric Intake Frm Page 1 f 3
4 Bld type (A/B/O) Has yur child been immunized? If s, has the recmmended schedule been fllwed? If nt, please explain Has there been any negative reactin t vaccinatins? FAMILY MEDICAL HISTORY D any clse relatives (grandparents, parents, siblings) have any f the fllwing medical cnditins? Disease Relative Disease Relative High Bld Pressure Birth Defects Heart Attack, Strke Suicide Obesity Depressin Diabetes Mental Illness Glaucma Autism Asthma Asperger s Hay Fever Alchlism Eczema Epilepsy Skin Disease Ulcers Fd Allergies Arthritis Emphysema Gut Tuberculsis Thyrid Disease Lung Cancer Easy Bleeding Breast Cancer Sickle Cell Anemia Other Cancer Osteprsis Othe r Has yur child lived in a huse built prir t 1973? Has yur child been expsed t a brken mercury thermmeter? Has yur child lived in a dwelling with mld r water damage? Has yur child lived, played, r gne t schl near: Agricultural spraying Pesticide applicatins Busy rads Des yur child s behavir change after: Eating certain fds Eating sugary fds Eating fds with dyes Hw ften des yur child have a bwel mvement? Idah Naturpathic Medicine Pediatric Intake Frm Page 2 f 3
5 BIRTH HISTORY Birth rder f this child Number f siblings Where there any cmplicatins during pregnancy r labr and delivery? Please explain. DIET Hw was yur child fed as an infant? Breast fed? Hw lng? Frmula? Type? What age did yur child begin eating slid fds? Which fds? Any unusual reactins t slid fds as an infant? Please describe yur child s typical daily diet. If breastfeeding, describe mther s diet. Breakfast Lunch Dinner Snacks Drinks Des yur child eat schl prepared meals r snacks? Which fds, cndiments, flavrs des yur child crave? Which fds, cndiments, flavrs des yur child dislike? Des yur child have any fd sensitivities r intlerances, either current r in the past? Is there anything yu wish t discuss abut behavir r emtins? If s, please explain. Is there any thing else yu wish t add? Thank yu fr taking the time t cmplete this frm. Idah Naturpathic Medicine Pediatric Intake Frm Page 3 f 3
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Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724)719-2441 / Fax (724)719-2451 100 Bradfrd Rad, Suite 410, Wexfrd, PA 15090 www.wexfrdallergy.cm New Patient Registratin and Medical Histry Name Tday s date
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