NEW PATIENT PACKET Welcome To Our Clinic!
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1 NEW PATIENT PACKET Welcome To Our Clinic! Name: Date: Address: City: State: Zip Code: Shipping address: Home phone: ( ) - Cell phone: ( ) - Date of Birth: Age: Gender: F / M / MTF / FTM Height: Weight: Marital Status: S M D W Occupation: Employer: Emergency Contact: Phone: Relationship: HOW DID YOU HEAR ABOUT US? Please rate your overall level of health (circle one): Excellent / Good / Fair / Poor What are your most important health concerns? List in order of importance. 1.) Onset: 2.) Onset: 3.) Onset: 4.) Onset: 5.) Onset: Name and location of current physician(s): 1
2 Date of last: Physical Female exam Dental visit Chiropractic visit Naturopathic visit Blood test Prostate exam Massage Acupuncture visit Mammogram ALLERGIES List all drug, food and environmental allergies: PAST MEDICAL HISTORY List any major illnesses with approx. dates: List any surgery or operations with approx. dates: Past accidents or injuries: FAMILY HISTORY Please list any medical conditions that run in your family (parents, siblings, grandparents, aunts and uncles): Cigarette smoking: Past Present smoking history Cigarettes: # each day x total years smoking Coffee/tea: ounces daily (1mug=14oz) Alcohol: # of beers, glasses of wine and hard alcoholic drinks per week Recreational drug usage: Exercise: Medications/supplements currently taking (please include dosage): 2
3 DIETARY INTAKE 2 DAYS PRIOR TO VISIT Day One Breakfast: Lunch: Dinner: Snacks/desserts: Water in glasses or ounces: Other drinks: Day Two Breakfast: Lunch: Dinner: Snacks/desserts: Water in glasses or ounces: Other drinks: 3
4 Patient Survey Please rate how serious you are about getting well t serious Very serious Are you willing to take nutritional and/or homeopathic supplements? Are you willing to make dietary changes? Are you willing to follow a treatment program designed to return you to health by treating the cause? Are you familiar with Applied Kinesiology? Please rate your current stress level on a scale stress Maximum Stress 4
5 Clinic Policies PLEASE READ CAREFULLY BEFORE INITIALING OR SIGNING. Please initial that you understand and agree to the following statements: Payment Agreement Payment for all services, tests, and medicinary items (that are not covered by your insurance) are due at the time of service. We accept all credit cards. Returned checks will be subject to a $25.00 NSF fee. Product Returns We use a variety of nutritional supplements, homeopathic remedies, and botanical medicines. Once these products leave our office, we cannot bear responsibility for their storage or their use. For the health and safety of our patients, we cannot accept returns on any medicinary products. Cancellations and Missed Appointments If you are unable to make your scheduled appointment, please call the clinic at least 24- hours in advance of your scheduled time. You will be charged a $40 missed appointment fee if you miss a scheduled appointment or fail to cancel at least 24-hours in advance. Correspondence The doctors at Columbia River Natural Medicine may use to correspond with patients as a convenience. However, these s are not encrypted and could theoretically be read by a malicious outside party with the technical skills to intercept such correspondences. By initialing this line, you are consenting to allow correspondence by and to other practitioners necessary for your care in spite of these potential risks. I have read and understand the above-stated policies and will comply with those I have initialed in all respects. If my insurance company requires release of my medical records, I hereby give my permission by signing this form. Print Name Signature of Patient/Guardian Date 5
6 Informed Consent PLEASE READ CAREFULLY BEFORE INITIALING OR SIGNING. Consent to Treatment The therapeutic procedures of naturopathic medicine are considered safe and effective methods of care. Any procedure intended to help may also have complications. While the chances of experiencing complications are small, it is the practice of this clinic to inform our patients about them. Please read and sign below that you understand the following procedures: Nutritional supplements, herbs, and homeopathy may be used to aid in healing. Be sure to inform your practitioner about all medications you are taking to minimize drug/supplement interactions. If you believe you are experiencing any side effects from your supplements/herbs/homeopathy be sure to alert your health care provider. Initial and circle if you have any severe food allergies to shellfish, gluten, soy, dairy, or other. Naturopathic Manipulation is a form of physical medicine. The practitioner uses gentle force to manipulate spinal segments or bones in the extremities to re-establish normal movement and function. Please alert your provider if you have previously had negative effects with naturopathic manipulation or chiropractic adjustments. Applied Kinesiology is a safe and non-invasive natural method of analyzing the body s physical and nutritional needs. It is not a method of diagnosing or treating any particular disease. I understand, and am informed that in the practice of medicine and naturopathy, there are some risks to treatment. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interest. I have read and understand the above statements and have had the opportunity to ask questions. I understand that the health improvement program recommended to me is not for the cure of any particular disease. promise or guarantee has been made regarding the results of Applied Kinesiology, or any natural health, nutritional or dietary programs. Rather, the above will be used for bringing about a more optimum state of health. By signing this form you consent to the treatments provided by the doctor(s) practicing at Columbia River Natural Medicine, LLC. Print Name Signature of Patient/Guardian Date 6
7 YOUR HEALTH INFORMATION PRIVACY RIGHTS Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain privacy rights concerning your health care information. Under this law your health care provider generally cannot give your information to your employer, use or share your information for marketing or advertising purposes, or share private notes about your mental health counseling sessions without your written consent. As one of your health care providers it is our responsibility to keep your information safe and secure. We also need to make sure that your information is protected in a way that does not interfere with your health care. It is important that you understand that your information can be used and shared in the following ways: For your treatment and care coordination Multiple health care providers may be involved in your treatment directly and indirectly. With your family, friends, relatives, or others that you identify who are involved in your health care or health care bills To protect the public s health, such as reporting when the flu is in your area To make required reports to the police, such as gunshot wounds Obtain payment from third party payers In order to provide you with service that best meets your privacy needs, please tell us how best to contact you when needed. Please check all that apply: Please do not phone me at home. Use this alternate phone number: Please do not phone me at work. Use this alternate phone number: Please do not call my cell phone. Use this alternate phone number: Please do not leave messages on my answering machine. Please do not contact me by . Please send mail, including my bills, to this alternate address: Other request (please describe): Print Name Signature of Patient/Guardian Date 7
PEDIATRIC INTAKE. Child s Name: Date: Name of Parent(s)/Legal Guardians: Relationship to child: Address: City: State: Zip Code:
PEDIATRIC INTAKE I appreciate your willingness to fill out this form as completely as possible. It is invaluable information for developing a treatment plan tailored to your child s individual needs. General
3 Flr Scotia Centre, Calgary, AB T2P 2W3 DR. KATHRYN DOYLE, ND! Phone: Fax: !!!!! Naturopathic Doctor! Adult Intake Form!
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FEE SCHEDULE & POLICY (OHIP) Meditech Rehabilitation Centres Inc. provides the following services: Updated: 19Oct17 1. Laser Therapy 2. Massage Therapy 3. Physiotherapy 4. Chiropractic Therapy 5. Exercise
Cheralyn Perkins, DPM David Scalzo, DPM Kathleen Hope, DPM Nicole Branning, DPM TODAY S DATE: / / LEGAL NAME: LAST FIRST MIDDLE
PATIENT INFORMATION PATIENT INTAKE FORM BANGOR PODIATRY, LLC Cheralyn Perkins, DPM David Scalzo, DPM Kathleen Hope, DPM Nicole Branning, DPM TODAY S DATE: / / LEGAL NAME: LAST FIRST MIDDLE ADDRESS: STREET
Gordley Family Chiropractic Clinic Patient Introduction Card. First Name MI Last Name Date Address Married Single Mailing Address City State Zip Code
Gordley Family Chiropractic Clinic Patient Introduction Card First Name MI Last Name Date Address Married Single Mailing Address Phone City State Zip Code Birth Date Social Security Number Employed By
SMITH CHIROPRACTIC HEALTH PROFILE Today s Date:
SMITH CHIROPRACTIC HEALTH PROFILE Today s Date: Name: Age: Male/Female DOB: Address: City: State: Zip: Home Phone:_ Cell: Cell Phone Provider: SSN#: Email Address: Single/Married/Divorced/Widowed Spouse
COMPLETE THIS PAGE FOR CHILDREN 4-8 YEARS OF AGE ASTHMA EAR INFECTIONS SORE THROAT BED WETTING HEADACHES UPSET STOMACH
COMPLETE THIS PAGE FOR CHILDREN 4-8 YEARS OF AGE CHILD S CURRENT HEALTH STATUS DURING PREGNANCY DID YOU USE: DRUGS/MEDICATIONS TOBACCO/ALCOHOL IF YES, DESCRIBE YOUR DELIVERY: CHILD S HEALTH HISTORY INSTRUCTIONS:
Kimberly Anne Hoffman, L.Ac. (HIPAA) CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS NAME
Kimberly Anne Hoffman, L.Ac. (HIPAA) CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS NAME BIRTHDATE EMAIL PHONE I understand that as part of my
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T 1 2 3 : Name _ Date / / Age Male/ Female Address City State Zip Phone: Home Cell Cell Phone Provider Email Address Date of Birth / / Occupation Employer Single / Married / Divorced / Widowed Spouse s
Family First Chiropractic
Family First Chiropractic Personal Information Title: (Check one) Mr. Mrs. Ms. Miss Other First Name Middle Initial Last Name Street City State Zip Code Email Home Phone ( ) - Cell Phone ( ) - Date of
Welcome To Our Office
Welcome To Our Office Mission Statement Our office is dedicated to educating and adjusting as many families as possible towards optimal health through natural chiropractic care. We believe the greatest
Family First Chiropractic
Personal Information Title: (Check one) Mr. Mrs. Ms. Miss Other First Name Middle Initial Last Name Street City State Zip Code Email Home Phone ( ) - Cell Phone ( ) - Date of Birth / / Sex: Male Female
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
CHISHOLM TRAIL ALLERGY AND ASTHMA PHONE (817) /FAX (817) DUTCH BRANCH ROAD, SUITE 200, FORT WORTH, TX
Today s Date: New Patient Registration and Medical History Patient Name: Nick Name: Address: Apt/Lot: City: State: Zip Code: Home Phone: Cell phone: Email: Is it ok to leave messages on the phone numbers
PATIENT INFORMATION FILL OUT ALL ITEMS
PATIENT INFORMATION FILL OUT ALL ITEMS FAILURE TO COMPLETELY FILL OUT THIS FORM MAY RESULT IN YOU BEING BILLED IN FULL Patient Last Name: First: MI:. Address:. Date of Birth: Gender: M or F Marital Status: