Additional Person To Contact In Case Of Emergency (if partner listed above is not available):
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- Audrey Davis
- 7 years ago
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1 Holistic Health Clinic 1530 South Union Avenue, Suite 4 Tacoma, WA Personal Information Home Phone Work Phone Cell Phone Mark the box next to contact number above that is the best way to reach you and is okay to leave a message. Birth Married/Partnered Single Age Your Partner (first contact in case of emergency) Business Business Phone Cell Phone Getting To Know You Is another family member/relative a patient here? Yes No Referred by: Internet Search/Our Website Yellow Pages Sign Insurance Provider Family Member Friend Other (Explain) Insurance Primary Carrier Insured s Group # ID # Secondary Carrier Insured s Group # ID # Account Information of Person Responsible for Account: Social Security # Business Business Phone Closest Relative Not Living With You: Relation Phone Additional Person To Contact In Case Of Emergency (if partner listed above is not available): Relationship Home Phone Cell Work
2 Financial Policy Payment: As a patient of this office you are directly responsible for payment of all charges incurred while under treatment unless you are eligible for insurance reimbursement with an insurance carrier the doctors have contracted with. Payments are due when services are rendered, supplies are received, or laboratory tests are ordered. If the doctor is contracted with your insurance carrier, all deductibles, co-pays and balances that are the patient s responsibility are due at the time of service. Accepted methods of payments are: personal checks, debit and credit Visa and Master cards, and cash. Insurance: If the doctor is contracted with your insurance carrier we will bill your insurance directly. We will make every effort to determine benefits and eligibility prior to treatment. What we are told by your insurance carrier will govern how we determine your liability. We are not responsible for payment discrepancies that might occur once the reimbursement check is received. It is the patient s responsibility to keep tract of their deductible, maximum benefit, or other liabilities specific to their plan s coverage. If you are not covered by one of our contracted carriers and think that your insurance will cover naturopathic care, at your request we will provide you with an insurance billing form that you can submit to receive payment from your insurance company. (Weight Loss Programs are not covered by insurance.) Senior Discount: A 10% discount on service (out-source lab, medications received from our dispensary and weight loss programs are not included) will be given to our patients who are age 65 or over. Due to State and Federal regulations, we cannot process medical coupons and Medicare/Medicaid claims. Cancellations: Please give us at least 24 hours advance notice of your inability to keep an appointment. If less than 24 hours notice is received the amount of the scheduled visit will be charged (except in emergencies). Late Fee: Accounts over ninety (90) days outstanding are overdue and may be acted on for collection. Collection costs are added to your account. A late fee of $1.50 or 1.0% of the balance per month, whichever is greater, is charged on overdue accounts. There is a $10.00 charge for returned checks and payment is due in the amount of the check plus the returned check fee within ten (10) working days. Authorization for Treatment I, the undersigned, hereby acknowledge that the care being provided at the Holistic Health Clinic is designed to improve my health or condition. I authorize the doctor to perform diagnostic tests deemed necessary for my care, to perform any and all forms of treatment, to include medication, and therapy that are indicated and that I am in agreement with and are in accordance with the Standards of Naturopathic Care. If procedures are performed, I have given my permission to do so and acknowledge that full disclosure of information has been made. I understand that every effort will be made by the office to fully disclose information about the procedures used. If I have questions about these procedures I will ask them until they are answered to my full satisfaction. I further acknowledge that there is no guarantee or warrantee, expressed or implied, concerning the outcome of any of the procedures used in the course of my care. If while under the doctor s care I experience a medical emergency, I am to dial 911. If I have a medical concern I am to phone the office to report. If my concern occurs during after hours I will phone the office where instructions on how to contact the doctor can be obtained on the after hours message prompts. I understand and agree to the above Financial Policy and Authorization for Treatment. I will abide by its terms. Signature of Patient or Responsible Party Patient (print) Responsible Party/relationship to patient (print) Witness Holistic Health Clinic 1530 South Union, Suite #4, Tacoma, WA
3 : Confidential Patient Health Record page 1 Age Birth F M Blood Type # of Children s & Ages List Your Current Health Problems Prioritize by listing the problems in order of importance Complete the following section for your top 3 problems (Check the bold descriptors that apply): Problem #1: Worsening or Improving? Why? Constant? or Intermittent? How does problem #1 effect your body / your life?: Problem #2: Worsening or Improving? Why? Constant? or Intermittent? How does problem #2 effect your body / your life?:
4 : : Confidential Patient Health Record page 2 Problem #3: Worsening or Improving? Why? Constant? or Intermittent? How does problem #3 effect your body / your life?: Use diagram to illustrate the areas on your body where you feel any of the following sensations: Use the following letters to mark the diagram: A = Numbness B = Deep Aching C = Burning D = Stabbing E = Pins & Needles F = Throbbing G = Itching General Information Have you seen a naturopathic doctor before? No Yes Are you currently seeing one? No Yes Doctor s name: Do you have a medical doctor? No Yes Doctor s name: Have you seen a chiropractic doctor before? No Yes Are you currently seeing one? No Yes Doctor s name: Do you see any other healthcare professional (i.e. acupuncturist, massage therapist, counselor)? No Yes Explain: What are the most significant measures that you have taken to improve your state of health? Tobacco Use: No Yes Smoke/Chew: years Amount Per Day: Year Stopped: Alcohol Use: No Yes Type: Frequency: Recreational Drug Use: No Yes Type: Frequency:
5 : : Confidential Patient Health Record page 3 Your Medical History List the prescription and non-prescription medications, vitamins, minerals, & herbs that you are currently taking: List any medications that have been prescribed, but you are not taking: List major illnesses, hospitalizations surgeries or serious injuries (include date & brief description): Allergies to drugs, food, or other substances? No Yes Height Weight Weight 1 year ago Max Weight When Minimum Adult Weight When Blood Pressure Heart Rate Personal Family History ( Unknown ) Please check and name who was affected (Self, Mother, Father, Grandparents, Sisters, Brothers, Children) AIDS/HIV Eczema Psoriasis Alcoholism Gout Senility Allergies Heart disease Sex abuse Anemia High blood pressure Seizures Arthritis Stroke Asthma Hypoglycemia Suicide Cancer Kidney disorder TB Depression Mental illness Thyroid problems Diabetes Migraines Ulcer Drug Problems Obesity Other Review of Systems Please check all the problems you have currently (in the past week): Constitutional Good general health Recent weight change Night sweats, fevers Fatigue/weakness Ears / Nose / Mouth / Throat Hearing loss or ringing Sinus problems Nose bleeds Sore throat/voice change Eyes Wear glasses/contacts Blurred/double vision Eye disease or injury Eye pain/dryness Cardiovascular Chest pain Palpitations Heart trouble Swelling hands/feet Lightheaded Respiratory Shortness of breath Cough Wheezing/Asthma Coughing up blood Gastrointestinal Nausea/vomiting Abdominal pain Rectal bleeding Indigestion/heartburn/reflux Constipation/diarrhea Musculoskeletal Muscle pain or cramps Stiffness/swelling joints Joint pain Trouble walking Neurological Frequent headaches Paralysis or tremors Convulsions/seizures Numbness/tingling Hematologic / Lymphatic Anemia Bruise easily Slow to heal Enlarged glands Endocrine Excessive thirst/urination Hair loss Cold hands and feet Hormone problems Light sensitivity Integumentary/Skin Abnormal nails Rashes or itching Breast irregularity Dry/discolored Skin Allergic / Immunologic Food allergies Frequent infections Hay fever Chemical Sensitivity Genitourinary Blood in urine Pain/burning on urination Frequent urination Kidney stones Genitourinary Continued Sexual problems Testicle/ovary pain Infertility Menstrual problems Psychiatric Insomnia Confusion/memory loss Depression Anxiety/panic attacks
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MAIN SATELLITE 49 Veronica Avenue Suite 202 901 West Main Street Suite 203 Somerset, NJ 08873 Freehold, NJ 07728 P: 732 640 5316 P: 732 640 5327 F: 800 689 2361 F: 800 689 2361 128 Rehill Avenue Suite
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FAIRBANKS PHYSICAL THERAPY
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Name Today's Date Sex. Street Address City State Zip Code. Home # Work # Cell # Would you like to receive text confirmations:
Patient Information 219 Old Hook Road Westwood, NJ 07675 Office: (201) 664-0847 Fax: (201) 664 8890 E-Mail: Mail@2020nj.com Thank you for choosing Valley Eye Associates for you eyecare needs. Please complete
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Florida Neurology, P.A.
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