Nambudripads Allergy Elimination Treatment - PATIENT REGISTRATION:
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- Clinton Caldwell
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1 Nambudripads Allergy Elimination Treatment - PATIENT REGISTRATION: Name: First, Middle, Last Name: Nickname: DOB: / / Your Address: City: State: Postal Code: Phone: NAET is alternative medicine and is a Cash Pay or Time of Service treatment only. See fees below: First Visit Evaluation : Establish treatment plan, goals and provide first NAET treatment. Follow up Basic treatment This treatment provides you thorough and complete NAET treatment but does not allow time for further education and assessment. It is provided to allow an affordable treatment option for everyone. Follow up Choice treatment This treatment provides you thorough and complete NAET treatment and allows time for further home and self-care education/review and to address more in depth treatment options. *This is my preferred follow-up option as I have the time to educate you more about your body and the treatments you are receiving. Follow up Re-assessment or Blended skill treatment option. This treatment option is to provide time to re-test after the first visits or re-assess a long list of items, it is also an option for treatments where someone would like to have an NAET visit and other helpful treatments like Craniosacral Therapy, Physical Therapy, Reiki, or other energy work /60 $140 $40 $70 $95/$120 *treatment duration may vary from visit to visit depending on item treated during visit. Signature: Date: 1
2 NAET Treatment Consent Form I,, certify that Sarah Dible, MSPT/NAET practitioner did not claim to cure any illness or disease with NAET (Nambudripad s Allergy Elimination Techniques). I understand that NAET is not a medical diagnostic procedure therefore does not diagnose any disease. Rather, NAET gives the practitioner an indication as to the substance(s) to which the patient may have sensitivity. NAET uses various, standard medically proven diagnostic measures and modalities (Allopathic, Chiropractic, kinesiological and Acupuncture) to diagnose the patient s condition. The premise behind NAET is to desensitize a patient to a substance(s) using Allopathic, Chiropractic, acupuncture/acupressure, nutritional, and kinesiological principles so that the patient may not experience hypersensitive symptoms when they have future contact with them. I understand that I am (my ward) to continue all medications and other treatment modalities as they have been prescribed unless otherwise directed by the doctor who prescribed them. During the 25 hours or after if I (my ward) get a life-threatening reaction from the allergen I (my ward) was treated or from some other sources, I need to seek emergency help immediately from a physician qualified in emergency treatments, or by calling 911 or attending an emergency room at the local hospital. If I (my ward) am suffering from severe allergic reactions to substances, I should consult an appropriate physician and take appropriated medication (such as medication to prevent itching, tissue swelling, fever, cough, pains, infections, mental irritability, violent behaviors, etc.) to keep my (my ward s) symptoms under control while I (my ward) am treating with NAET treatments. This way, essential NAET treatments can be completed without interruption and once I (my ward) complete the essential NAET treatments for my (my ward s) condition, I (my ward) may not need to continue pharmaceutical drugs indefinitely. I understand that for 25 hours after the treatment I (my ward) am to avoid eating, touching, breathing and coming within 5 feet of the substance(s) that I (my ward) have received treatment. If I (my ward) come in contact with substance(s) for which I (my ward) am being treated, I realize that the treatment may not work and I (my ward) may have a sensitivity reaction. I understand that I (my ward) must return after my 25 hours avoidance period preferably within 7 days, to see if I (my ward) have cleared for the substance(s). I fully understand that I (my ward) may still experience a reaction to the substance(s) of unknown severity if I (my ward) come in contact with them if I (my ward) did not clear them completely. If I (my ward) did not clear them completely, I (my ward) may be required to repeat the procedure (more office visits at my cost) until I (my ward) clear them satisfactorily. I understand that this document will be filed in my records and will apply to my initial session as well as all additional sessions. I have read or have had read to me the above statements and have had the opportunity to ask questions about its content and by signing below I agree to the terms and procedures. Patient s Signature Date Name of the Minor Relationship to the minor (ward) 2
3 SARAH DIBLE MSPT/REJUVENANCE THERAPY PATIENT CONSENT/WAIVER: HEALTH INFORMATION: Your personal health information, which includes your entire medical history and information about services provided to you, is protected by law. This health record serves as a basis for planning your treatment, communication between your health care professionals, legal documentation, verification of treatment for third party payers, and a tool to improve your care based on outcomes. Although this record is the physical property of the health care provider, this information also belongs to you and you have rights regarding the privacy of your records. A detailed explanation of these rights is available at the front desk and a copy is available to you upon request. In order to provide the best care possible, we may need to discuss your case with other health care professionals and health care facilities. By signing below, I authorize Rejuvenance Therapy or Sarah Dible, MSPT to release my medical records to my physician and my other health care professionals. I also authorize Rejuvenance Therapy to request pertinent medical records from these professionals (including copies of related imaging.)please list pertinent health professionals and their contact information: I understand that my health information may include information both created and received by the clinic, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information. By signing below, I agree that I have been informed about this privacy practice and my protected health information and how to obtain a personal copy of this form and privacy policy. CONSENT TO TREAT: You are an important partner in your health care decisions and play an active role in the outcome of your medical care. Thus, it is important that you are informed about benefits, risks, evaluations, and decisions about your care while being seen at this office. If you have questions, symptoms, or problems related to your care it is your responsibility to notify your physical therapist and consult with your primary care provider as necessary. CREDIT AND PAYMENT POLICIES: Our goal is to provide you with the highest quality care at a reasonable cost. Cash-pay patients will be expected to pay for services in full at the conclusion of their appointment. PATIENT MISSED APPOINTMENT POLICY: We are committed to fully assist you with your rehabilitation needs and thus, you are expected to attend all of your appointments. We are reserving this time specifically for you. If you need to cancel or reschedule an appointment, please do so 24- hours prior to your appointment time. A $25 fee will be charged for sessions missed without such prior notification. This fee will be due prior to your next treatment (insurance is not responsible for this fee.) All cancellations and no shows are documented in your medical record. We understand there are occasional emergency situations and we appreciate your consideration of our time. In instances of repeated non-compliance with scheduled visits, we reserve the right to discontinue care. By signing below, you agree to this policy. By signing below, I agree to be treated by Rejuvenance Therapy Sarah Dible, MSPT, knowing there may be potential risks along with benefits, and I am willing to be an active participant in my own care. Signature: Date: 3
4 Health History Questionnaire: Briefly describe the problem that brings you here today: Date the above problem started: Other treatments you have had for this problem: Please list any known allergies and their symptoms: Please list any medications or supplements that you are currently taking: General Health History: check all that apply [ ] Arthritis [ ] Stroke [ ] Fibromyalgia [ ] Cancer: [ ] In remission [ ] Stomach Disorders [ ] Headaches [ ]Diabetes [ ] Anxiety [ ] Hearing Problems [ ]Heart Disease [ ] Back Injury [ ] Numbness or Tingling [ ] High Blood Pressure [ ] Pacemaker [ ] Arthritis RA/OA [ ] Lung Disease [ ] Visual Problems [ ] Allergies/Hay Fever [ ] Allergies [ ] Kidney Disease [ ] Sleep Disorders [ ] Asthma [ ] Skin Disorder [ ] Head Injury [ ] Epilepsy [ ] Osteoporosis [ ] Fracture [ ] Chronic Pain [ ] Fatigue [ ] Hernia Current pain level: No Pain Too much pain Is your symptom [ ] Constant [ ] Increasing Decreasing [ ] Staying the same [ ] Occasional What makes your symptom worse? Prior to your symptoms or problem, what activities could you do that you are unable to do now? 4
5 Your usual activity level: [ ] Low [ ] Medium [ ] High Do you smoke? [ ]Yes [ ]No Do you exercise regularly? [ ]Yes [ ]No Do you use drugs? [ ]Yes [ ]No If there are physical symptoms (ex: rash, pain etc..) Please use this diagram to indicate your symptoms: What are your personal goals for NAET? 1) 2) 3) 4) Please include any other information you feel will helpful for your care: 5
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MASSAGE I TAKE FORM RAQUEL CARTER LICE SED MASSAGE THERAPIST EXERCISE PHYSIOLOGIST REFLEXOLOGIST
MASSAGE I TAKE FORM RAQUEL CARTER LICE SED MASSAGE THERAPIST EXERCISE PHYSIOLOGIST REFLEXOLOGIST CLIE T I FORMATIO NAME: DATE: Last First Middle Initial BIRTHDAY: MARITAL STATUS: S M W D DP ADDRESS: Street
ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
NAME: ABOUT YOU WHO REFERRED YOU TO OUR OFFICE? CHIROPRACTIC EXPERIENCE ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: How did you hear about our office? NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT
PLEASE NOTE: This file must be saved to your desktop before and after completing!
PATIENT INFORMATION PLEASE NOTE: This file must be saved to your desktop before and after completing! Date First Name Middle Name Last Name SSN Sex Birth Date Height Weight Marital Status Spouse Name Number
Phoenix Community Acupuncture s Fine Print -Please initial each section, then sign and date the back. Thank you.-
Phoenix Community Acupuncture s Fine Print -Please initial each section, then sign and date the back. Thank you.- INFORMED CONSENT Acupuncture involves the insertion of special needles into particular
Who? When? Results? Please Mark P For In The Past OR Mark C For Currently Have:
T, CD, E, C New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Email Address Occupation Employer s Name Single / Married / Divorced / Widowed
North Jersey Physical Therapy Medical History Questionnaire. Name: Date of Birth: Age: Occupation: Currently working?:
Today s Date: North Jersey Physical Therapy Medical History Questionnaire Name: Date of Birth: Age: Occupation: Currently working?: How did you hear about our practice: Referring Physician (full name &
In order to receive the maximum benefit from your rehabilitation program, it is important to understand and comply with the following guidelines:
Arrival Policy 900 2 nd Ave., Madison, MN 56256 In order to receive the maximum benefit from your rehabilitation program, it is important to understand and comply with the following guidelines: Attend
Client Intake Form. Phone:
Client Intake Form Name: Last First Date: Address: City: ST: Zip: Email: Phone: How did you hear about Skin Renew Day Spa? What are your main concerns? How long have you been experiencing your current
6140 W Atlantic Avenue * Delray Beach, FL Tel: (561) * (888) 357-DERM * Fax: (561)
Cosmetic Patient Information Today s Date: Reason for visit: Patient Name: (Last) (First) (Middle) Permanent Address (Local): Street City/State/Zip Secondary (Out of State) Address: Street City/State/Zip
DATE: Dear Mr./Mrs./Ms., location.
Consultants in Pain Medicine, P.A. 5368 Fredericksburg Road Legacy Oaks Building C Ste. 210 San Antonio, Texas 78229 Phone (210) 546-1470 Fax (210) 546-1479 DATE: Dear Mr./Mrs./Ms., You have been referred
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
PATIENT NAME DATE CONSULTATION QUESTIONNAIRE
CONSULTATION QUESTIONNAIRE 1. What is your major symptom? 2. What does this prevent you from doing or enjoying? 3. If this is a recurrence, when was the first time you noticed this problem? How did it
HEALTH RECORD REASON FOR THIS VISIT ABOUT YOU ABOUT YOUR SPOUSE HEALTH HABITS EXPERIENCE WITH CHIROPRACTIC
HEALTH RECORD ABOUT YOU REASON FOR THIS VISIT Name Address City State Zip _Home phone Birth date Cell Phone Age Gender Number of children Employer Work address Work phone Occupation Marital Status Social