o Married 0 Widowed 0 Singk 0 Minor o Separated 0 Divorced 0 Partnered for ~_\'ears

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1 WELCOME ================================ =====~ P.~AT1E_NT_r1Y19RMA TION Date. 6 SEELEY LAN~. ELIV 1, lyj... VJ/v", PA TrENT CONDITION Reason for Visit. SS# Patient Name ~ : : Last Name First Name Middk Initial Address City ~_ State lip Codc Sex OM OF Age Birth date o Married 0 Widowed 0 Singk 0 Minor o Separated 0 Divorced 0 Partnered for ~_\'ears Occupation, Patient EmployerISchool. Do you sutfer from symptoms or problems with an)' of the following?: Arthritis Asthma Allergies Colitis Constipation Diabetes Diarrhea Diverticulitis Hemorrhoids Headaches Heart Problems Candidiasis Fatigue Bad Breath Indigestion Backache Uterus Kidne~ Prostate Skin Disorders Eye Foot aches Genitals GastritiS Cancer Bleeding w/stools IBS Do you use'~ Aspirin Antacids ;Bowel Movements? EmployeriSchool Address._~ Spouse', Name. Birth date. Number per day :Odor Color Shape, Spouses's Employer Whom may we thank for reterring you J Do you have Insurance? _Yes _No I r Yes. Who: o==='='phone NUMBEI~S.~==== Home Phone (_) Do YOli receive chiropractic care? Yes No ITfYes. how often?!do you know your blood pressure? Do you know your pulse rate? Cell Phone L) Best time to reach YOU TN CASE Of EMERG:;;E;::;:N:7:C:::Y:,=C==O::N=T=A=C''T' Name Relationship Home Phone (_)_' Work Phone (_)._..... _.

2 _... a.._ _.'" _. r f\ 1 1 ~ 1't 1 11 ~ r V.l'\.l 'f J..M.. _1._1.:...'"'"1_' Vhat treatment have you already received for ~ our condition: Medications Surgery Other None Date of your last Colonoscopy: )ate of >'our last Physical Exam: s there any thing else you would like the doctor to know about your condition? Place a mark on "Yes" or "No" to indicate if you hay e had an~ of the following:.... _._.. _ _... _.... AIDS/HIV 't'es No Diabetes Yes No Migraine Headaches Yes No Rheumatic Fever Yes No' Alcoholism Yes No Emphysema Yes No Miscarriage Yes No Scarlet Fever Yes _No Allergy Shots Yes No Epi1eps~ Yes No Mononucleosis Yes ~No Stroke Yes No Anemia Yes No Fractures Yes No Multiple Sclerosis Yes No Suicide Attempt Yes No /\norexia Yes No Glaucoma Yes No Mumps Yes No Thyroid Problems Yes No, Appendicitis Yes _No Goiter Yes No Osteoporosis Yes No Tonsillitis Yes No Asthma Yes No Gonorrhea Yes No Pacemaker Yes No Tuberculosis Yes No: Bleeding Disorders Yes No Gout Yes No Parkinson's Diseases Yes No Tumors. Growths Yes _No, Breast Lump Yes No Hear Disease Yes No Pinched Nerve Yes _,No Typhoid Fever Yes No! i Bronchitis Yes No Hepatitis Yes No Pneumonia Yes No Ulcers Yes _No! Bulimia Yes No Hernia Yes No Polio Yes No ' Vaginal Infection Yes No No Venereal Disease Yes _No Cancer Yes No Herniated Disk Yes No Prostate Problem Yes Cataracts Yes No Herpes Yes No Prosthesis Yes No Whooping Cough Yes No: Chemical High Cholesterol Yes No Psychiatric Care Yes No Other Dependency 'r'.:s No Kidney Diseasl! Yes No Rheumatoid Chicken Pox Y.:s No Liver Disea~e Yes No Arthritis Yes _No ~._. Exercise: Work Activity: \1ea~les None Sitting.. _....._ Yes No Standing Moderate Daily Heavy Light Labor Heavy Labor! Habits: Smoking Packs/Day Alcohol Drinks/Week Coffee/Caffeinebrinks Cups/Day High Stress Level Re~on; Are you Pregnant? Yes No If Yes. Due Date Injuries/Surgeries you have had: Such as: Falls HeadI~uries ~ Broken Bones Dislocations Medications: Allergies: V itamins/herbs/minerals:

3 NOTICE TO ALL COLON HYDROTHERAPY,"~D l\1a,ssage CLIENTS Due to the high demand for appointments for colon hydrotherapy and massage, we need to require a minimum of 24 hour notice to cancel an appointment or you will be billed the regular session fee. These appointments are reserved for you and cannot be rearranged for others awaiting an appointment with short notjce. We understand that there are times when exceptions "rill be necessary. These exceptions "Jill be accepted at the discretion of the practitioners. fhank you for you cooperation in this matter. "'I' ngnature:

4 NATURAL CARE WELLNESS CEN1'Elt DR SCOTI AND DR. JODY FE:RREIRA 6 SEELEY LANE (RT.. 236) ELIOT, ME tt.~. AUIHORIZATION, AsSIGNMENT AND CONSENT TO TREAT Our office policy :requires payment in full for all services TSldered a the time of visit.. unless other arrangements have been made with the business manager. If the account 15 not paid w.ithin 90 days of the date of service, and no.financial arrangement bas been made, you :will be responsible for any expenses incurred. in collecting your account ~, I hereby authorize NATIJRAL CARE WELLNESS CENTER to bill the insurnnce company for services rendered on my behalf. The bullingof such services are a privilege and not a guarantee of coverage. I further authorize the physician and/or supplier to release any information required to process insurance claims. ~, I authorize the direct payment to you. any sum I now or hereafter owe, by nly attorney out of the proceeds of any serjement of my case, and/or by any insurance company obligated to make payment to me or you based in vvilole or part upon the charges made for the services.. ~ I understand that v,.'hal:ever amounts you do not collect from the insurance company and/or attorney, whether it be ali or part of"':b.at is due, I personally owe and agree to pay you. I ~ereby aujiorj.ze the doctot's ofna ThKAL CARE VY"ELLNESS CENTER and :~mever: they designate as their assistant or authorized representative to administer ~~~~~~c care, acupuncture or colon hydrotherapy as they deem necessary. We invite :~...,ou. l~ msc: uss. openly treatment, services, and charges rendered at this office, so tl:1at,,,ere IS!:<lcrtual agreement and c1.a::tity. Si21lat'''"'"''''... ' Date: Si~a:.~e c:fg~dian ifpatientjs under 18 years of age:... Date:

5 NATURAL CARE WELLNESS CENTER DR SCOTT AND DR. JODY FERREIRA.6 SEELEY LANE (RT. 236) ELIOT, lvie INDIVIDUAL PATIENTS' AUTHORIZATION This authorization is to confirm or deny the use or disclosure of protected health information. i Patient~s;Name:,.:Date: Please ~tial on all that apply. If you do not agree WIth any statements, please mark an X on the blank to confirm that you have read and understood the statement. I _ I a~orize the release of my medical records to my family practitioner or other physiciar. List Names r authorize the release of my medical records to my health insurance company for payment of services rendered.!! :I au1h0rize the release of my medical records to any third party payer including msuran~, workman compensation, attorney, auto insurance, etc. I authorize NATURAL CARE V1ELL:N""ESS CTh'TER to send information to my house c9ncerning birthdays or newsletters, etc...' I aufuorize NA TtJRAL CARE WELLN'"ESS CD: 1 J::.R to leave any message on my home or!work answering machine such as appointtne~t {ime.

6 0, PRIVACY PRACTICES ACKNOWUlDGISMlNt ACKNOWLEDGEMENT FORM I have received the Notice of Privacy Practices and I have been provided an opportunity to review it. Name Birtfldate Signarure ~ Dam.o...".;:,; ~.:::