FAMILY INFORMATION. City: State:..Zip:. Home Phone Number:.. Parent/Guardian #2: Name: Cell:.. .

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1 Date:... FAMILY INFORMATION New Patient Information: Child s First & Last Name:... Date of Birth:.. Age: Sex: Parent or Guardian Information: Names of Parents/Guardians:.. Address: City: State: Zip:. Home Phone Number:.. Parent/Guardian #1: Name: Cell:.. Parent/Guardian #2: Name: Cell:.. . Child s Additional Home Address (if applicable): Names of Parents/Guardians:.. Address: City: State:..Zip:. How did you hear about our practice? Referred by:... Insurance Information: Insurance Company Name:. Policy Holder s Name: DOB:. Subscriber ID #:.Group #: Insurance Company Address: Insurance Company Phone Number:

2 OFFICE POLICIES All visits must be scheduled. To schedule a visit, please call the office at Same day urgent appointments are generally available. OFFICE HOURS Monday: 9am - 5 pm (office closed from 1-2pm) Tuesday: 9am - 5 pm (office closed from 1-2pm) Wednesday : 9am - 1pm Thursday: 9am -5 pm (office closed from 1-2pm) Friday: 9am - 5 pm (office closed from 12-1pm) Please arrive 5-10 minutes prior to your scheduled appointment time. Our office schedules only one patient at a time and we pride ourselves on being timely. Arriving a bit early ensures that you will be ready for your visit to start on time. For After-Hours urgent issues call our office at Dr. Roy is available 24 hours a day for regular patients. Follow the instructions on our office voice mail to be transferred to Dr. Roy s personal cell phone after hours. For life or limb threatening emergencies, call 911 immediately. Communication: Giving medical advice is complex and often requires a dialogue that is better handled in person or by telephone. For this reason, we do not respond to medical questions via . FINANCIAL POLICY Thank you for choosing Mindful Pediatrics where we are committed to providing the highest quality medical care and experience possible. The following statement explains our financial policy, which we ask that you read, initial, sign and return to us prior to your visit. Your payment is due in full at the time of service. We accept cash, check or credit cards (Visa, MasterCard & Discover only). Mindful Pediatrics does not accept any insurance. We will provide you with a Super Bill for you to submit to your insurance company for reimbursement based on your out of network coverage. Office Rates: New Patient Appointment: $360 Well Child Care: $245 Sick Visit: $130 Follow-Up Visit: (for lab review, discussion of ongoing issues): $130-$245 Vaccine Only Visit: $40 plus cost of vaccines (we do not charge a visit fee for flu shots) *Certain circumstances will require additional visit types that will be discussed prior to scheduling.

3 Missed appointments: We require a minimum of 48-hours (2 business days) notice of cancellation prior to your scheduled appointment. In the event of less than 48-hour cancellations, patients will be charged for their missed appointment in full. Although Mindful Pediatrics uses an reminder system as a courtesy to our patients, it is ultimately the patient s sole responsibility to remember their appointment date and time. Credit Card on File: We require a current credit card to be kept on file for each patient. The patient/guardian acknowledges that this credit card will be charged in full in the event of a missed appointment not cancelled at least 48 hours ahead of time. Returned Checks: For checks returned to us as unpaid by your bank, you will be charged a $35 processing fee in addition to the original amount of the returned check. Legal: Dr. Roy does not participate in legal evaluation and will not testify in court on your legal issues. In the event Dr. Roy is mandated by the court to participate in your legal affairs, you will be charged for any time incurred for such issues. Acknowledgment of Notice of Privacy Practices and Consent to Treat I, (Parent/Legal Guardian):..., hereby acknowledge that I read and reviewed a copy of Mindful Pediatrics Notice of Privacy Practices and fully understand this consent form. I understand the risks associated with online communications between my physician and me, and consent to the conditions outlined herein. I also understand that I am financially responsible for the charges that I incur during my child s treatment under the care of Mindful Pediatrics. I have read and agree to the financial policy. As the child s parent/guardian I understand that I am consenting for my child to be treated. I have been proactive about asking questions related to this consent agreement. My questions have been answered and I understand and concur with the information provided in the answers.. Date Signature of Parent/Legal Guardian.. Print Name

4 CANCELLATION POLICY A minimum of 48-hours notice (2 business days) is required for cancelling/rescheduling any appointment. For example, an appointment scheduled for 11:00 am Thursday must be cancelled or rescheduled two business days prior by 11:00 am Tuesday to not incur the appointment fee. Appointments scheduled for Mondays or Tuesdays need to be cancelled or changed by the prior Thursday or Friday, respectively. Mindful Pediatrics takes pride in our policy of scheduling only one patient at a time. Unlike other doctor s offices who schedule 2 or 3 patients in the same time-slot (which is why you generally wait minutes to be seen), at our office your appointment time is reserved exclusively for your child. In keeping with our philosophy, this allows us to serve our patients in the best way possible but also limits the number of patients we can accommodate in any given day. In addition, we generally have patients who are on a wait-list for when appointments become available and a 48- hour cancellation/reschedule policy allows us to accommodate those patients in a timelier manner. The overwhelming majority of cancellations and appointment change requests we receive are not due to unforeseen emergencies, but are a result of scheduling changes or conflicts that are known well in advance. Requiring a 48-hour cancellation policy will allow us to accommodate new and existing patients in a timelier manner. We care about our patients and we want you to know that our cancellation policy is not a punishment, but a system based on mutual respect. 98% of our patients understand this. Very rarely, we have a patient who will feel that they are being punished by being charged for their missed appointment. We want to make sure that you don t feel this way (if someday you miss an appointment), and therefore it is important to be clear about this ahead of time. We try our best to help you avoid cancellation fees by using an reminder system. Although we do this as a courtesy to our patients, please understand that remembering the date and time of your appointment is your responsibility. Unavoidable circumstances may warrant special consideration, but please note that the full appointment fee will apply to most cancellations without greater than 48-hours notice. Cancellations/reschedules with greater than 48-hours notice (2 business days) incur no charges In the event that you cancel/reschedule your appointment with less than 48-hours notice (2 business days), you will be charged the entire appointment fee In the event of a missed appointment, without notification of cancellation, you will be charged the entire appointment fee. Date Signature of Parent/Legal Guardian.. Print Name

5 NEW PATIENT MEDICAL HISTORY Patient Name:...Patient DOB:..Patient Age: Parents Name(s): Please List Other Siblings: Sibling Name:.Age:. Sibling Name:.Age:. Sibling Name:.Age:. Sibling Name:.Age:. Parents Occupation: Name:. Occupation:... Name:. Occupation:... What are your child s most important health problem(s)? List as many as you can in order of importance: How long has your child been experiencing this? How long has your child been experiencing this? How long has your child been experiencing this?.. Has your child had any hospitalizations, surgeries or injuries? If so, please list and give approximate date:.... Does your child have any medication allergies? If so, to what?... Does your child have any food allergies or sensitivities? If so, please list:... Does your child take any regular medications? If so, please list: Medication Name: (i.e. Zantac) Dose: (15 mg twice daily) For how long? (3 mos) Approximately how many times has your child been on antibiotics?.. For what conditions?...

6 Please list any supplements or herbs your child takes regularly: If your child is currently nursing, please also list supplements that Mom is taking: Supplement Type: (i.e. Vitamin C) Manufacturer (i.e Thorne) Dose (i.e. 500mg) Please check any recurring or chronic issues below: Ear infections Frequent colds. Pneumonia. Sinus problems. Hay fever.. Allergies Chronic runny nose.. Headaches.. Seizures. Temper tantrums Hyperactivity. Impulsive behavior Spacing out. Difficulty concentrating. Gassiness. Abdominal pain Diarrhea Constipation.. Digestive difficulties. Hives Eczema.. Other Rashes. Asthma.. Coughing/wheezing. Depression.. Anxiety. FAMILY MEDICAL HISTORY Does the child s sibling, mother, father, grandparent or other genetic relative have/had any of the following? If yes, please indicate relationship to child: High Blood Pressure (Hypertension):.. High Cholesterol (Hyperlipidemia): Heart Attack (indicate approximate age): Stroke: Irregular Heart Rhythm (Arrhythmia):. Diabetes:.. Asthma:. Allergies (include type):. Autoimmune Illness:

7 Thyroid Issues:... Celiac Disease:. Crohn s Disease or Ulcerative Colitis (IBD):. Irritable Bowel Syndrome (IBS):.. Reflux or Ulcers:. Other Digestive Issues:.. Depression: Anxiety:. Other Mental Illness:.. Blood Clotting or Bleeding Disorder: Cancer (indicate type):.. Genetic Abnormalities:.. Tuberculosis:. Drug Abuse: Alcoholism:. Learning Difficulties:. ADD/ADHD: Seizure Disorder:. Other Neurologic issues:.. Hearing Loss (indicate approximate age):. Kidney Disease: Other (Please list anything not mentioned above):.

8 Mindful Pediatrics Vaccine Informed Decision I understand that vaccines are given to protect both the individual and the general population against catching and spreading certain serious infectious diseases. The way that vaccines are administered shall conform to recognized standards of medical practice in accordance with U.S. Department of Health and Human Services, Public Health Service s Recommendations of the Advisory Committee on Immunization Practices (ACIP), and the latest Report of the Committee of Infectious Diseases of the American Academy of Pediatrics (Red Book). To exercise my right of informed consent, I may use all resources available to me to become more fully informed about vaccine contents, effectiveness, safety, and possible side effects. It is my responsibility to make myself aware of the Colorado State and Federal laws pertaining to vaccine administration and exemption. I have been provided with and read all the Centers for Disease Control and Prevention s (CDC) Vaccine Information Statements (VIS) before administration of any vaccines. I have had the opportunity to discuss these vaccines with my child s health care provider, who has answered all of my questions regarding the recommended vaccine(s). I understand the following: The purpose of and the need for the recommended vaccine(s) The risks and benefits of the recommended vaccine(s) If my child does not receive the vaccine(s), the consequences may include: -Contracting the illness the vaccine should prevent. -Transmitting the disease to others. -The need for my child to stay out of child care, school, or possibly be quarantined during disease outbreaks. I recognize that adverse reactions to vaccines sometimes do occur. I am aware that the American Academy of Pediatrics and Center for Disease Control and Prevention strongly recommend all of the following vaccines be given: Hepatitis B, Diphtheria, Tetanus and acellular Pertussis (DTaP, TDaP, DT, or Td), Haemophilus influenzae type b (Hib), Pneumococcal conjugate or polysaccharide (Prevnar), Inactivated poliovirus (IPV), Measles-mumps-rubella (MMR), Varicella (chickenpox), Influenza (flu), Meningococcal conjugate or polysaccharide, Hepatitis A, Rotavirus and Human Papillomavirus (HPV). By making this informed decision I do not hold the health care provider liable for any potential negative outcome, whether it is from the giving or withholding of any or all vaccines. Signature of Parent/ Legal Guardian Date. Print Name of Parent/ Legal Guardian Patient Name