Naturopathic Intake Form
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- Lydia Rice
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1 Naturopathic Intake Form Date: Name: Date of Birth: _ Are you related to any other patients? Sex:! M! F Marital Status:! Single! Married! Divorced! Widowed Profession: Cultural Heritage: Place of Birth: How did you find our clinic? Please circle one below. Referral naturalcareclinic.ca Google Yellow pages 411.ca yellowpages.ca canpages.ca Other Contact Information: Address: _ Home Telephone: City: Work Telephone: Postal Code: Cell Telephone: address: Would you like our montly e-newsletter sent to your ?! Yes! No Emergency Contact Information: Who can we contact in an emergency situation? How are you related to this person? Home Telephone: Work Telephone: Have you ever seen a Naturopath before?! No! Yes Page 1 of 5
2 Who is your Medical Doctor and when was the last visit? Who is your Specialist (if any)? When was your last visit? Who is your Chiropractor? Who is your massage therapist? Who is your Dentist and when was the last visit? _ List Any Known Allergies: Daily Diet Please indicate what you would ingest during the course of a day. Breakfast: _ Lunch: Dinner: Snacks: Liquid: Medical History What is your main reason for treatment? How long have you been suffering with this condition? What diagnosis has your medical doctor given you? What prescription drugs are you currently taking? This includes the birth control pill for women. Please include medication dose if possible. Page 2 of 5
3 What prescription drugs have you taken in the past? Please include dose if possible. What supplements are you currently taking? Please provide the date and type of medical intervention, such as surgery, hospital visits or disease diagnosis dates: Date Description Have you ever has any of the following illnesses? Please circle. Measles Whooping Cough Pneumonia German Measles Chicken Pox Polio Mumps Small pox Pleurisy Scarlet Fever Tuberculosis Other: Page 3 of 5
4 DIETARY PROTOCOL: PROTOCOL YES NO Gluten Free Grain Free Allowed Foods: Beans, Legumes, Lentils Quinoa Tapioca, Arrowroot Starch Potato Sweet Potato Rice Other: Dairy Free Egg Free OTHER: Page 4 of 5
5 Informed Consent for Naturopathic Treatment Naturopathic medicine is the treatment and prevention of disease by natural means. Naturopathic Doctors assess the whole person, taking into consideration physical, mental, emotional and spiritual aspects of the individual. Gentle, non-invasive techniques are generally used in order to stimulate the body s inherent healing capacity. Your Naturopathic Doctor at Natural Care Clinic will take a thorough case history, perform a physical examination and may request urine samples or require blood tests. It is very important that you inform your Naturopathic Doctor immediately of any disease process that you are suffering from and any medications/over the counter drugs that you are currently taking. You will receive information about your diagnosis and will be provided with a treatment protocol, alternative courses of action, the material effects, costs, expected benefits, risks, and side-effects and in each case the consequences of not following the treatment advised. There is some slight health risks associated with treatment by naturopathic medicine. These include but are not limited to: Homeopathic remedies may occasionally result in the aggravation of pre-existing symptoms. When this occurs the duration is usually short, however beneficial for your health. Some patients may experience previously unknown allergies to herbs or supplements. Please advise your Naturopathic Doctor of any known allergies you may have. Muscle strains and sprains or disc injuries from manipulation. I have read the above and hereby give consent to Naturopathic treatment for myself. Patient Name: (please print name) Signature of Patient: Date: Page 5 of 5
6 CREDIT CARD AUTHORIZATION FORM & CANCELLATION POLICY Frequent cancellations and no shows have forced us to create a policy that ensures 48 hour notice for all cancellations and a charge for the full scheduled visit for a no show. This policy ensures that Natural Care Clinic runs smoothly and that patients and clients booking appointments can receive treatment as soon as possible. In lieu of my credit card imprint, I, hereby authorize NATURAL CARE CLINIC to make charges in the amount equivalent to the cost of my full scheduled visit to my Credit Card. I fully understand the payment is non-refundable if I do not cancel my appointment 48 hours in advance. Your credit card will not be charged unless an appointment is missed without 48 hours notice. Client s Full Name Phone: Fax: Credit card Type: (please check mark) ( ) Visa ( ) MasterCard ( ) American Express Credit card number: Expiration Date Last three digits on the back of the credit card Cardholder s Name (as it appears on credit card): Card Holder s Billing Address (where credit card statements are sent) if different from above Address Postal Code City Cardholder s Signature: Date: I understand: That Natural Care Clinic does not guarantee treatment results. That my Naturopathic Doctor will explain to me the exact nature of any treatment provided and will answer any questions I may have. That if I miss an appointment or cancel an appointment without 48 hours prior notice I have to pay 50% of the visit. That I am free to withdraw my consent and to discontinue my treatment at any time. Page 6 of 5
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FROM: TOTAL NO. OF PAGES, INCLUDING COVER: FACSIMILE TRANSMITTAL SHEET
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Vibrant Health Naturopathic Medical Center & Clinical Thermography Dr. Nicole Schertell 100 Shattuck Way, Newington, NH 03801 (603) 431-6677 or (603) 610-7718 1-888-796-2862 fax Welcome! Vibrant Health
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10301 Democracy Lane Suite 201 Fairfax, VA 22030 Phone: 703-547-3509 Fax: 703-383-3887 www.rrpsychgroup.com Date: PERSONAL DATA please mark with an asterisk (*) your preferred mode of contact Client Name: