Congratulations on taking a positive step toward improving your health! Enclosed please find a New Patient Packet which includes:

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1 Congratulations on taking a positive step toward improving your health! Enclosed please find a New Patient Packet which includes: Medical History Intake Form. Once completed, please return the form and you will then be contacted to schedule an appointment. A credit card number will be required at the time of scheduling to reserve your appointment time. (MasterCard and Visa accepted) Information regarding Costs, Payment Policy, and Insurance information. Client Provider Agreement. If applicable, please include the Following Medical Recordsthese can be mailed to the office ahead of time or bring them with you to your scheduled appointment: Most recent PSA blood test results Most recent prostate exam notes All blood work completed within the last year 4. Any other information pertinent to your situation Thank you for your cooperation and I look forward to meeting with you soon. Sincerely, Lynn Lynn A. Chadd, MSN, ARNP

2 General Office Information: New Patient Consult Appointment is $ due at the time of service. (Includes 1 st follow up appointment)--please allow minutes for this New Patient appointment. Consult appointments can be face to face in the Poulsbo or Peshastin office or on the Telephone for our long distance patients the cost is the same. Saliva Hormone Test is $ Saliva Testing is required to be treated with bio-identical hormones. On average, saliva testing is completed when treatment is initiated, when prescriptions are adjusted and yearly when treatment has stabilized. Frequency of saliva testing will vary from person to person, depending on response to treatment. Kits are purchased through our office. Follow up to review results is not included in the cost of the test. Established Patient Follow Up Appointment cost $ A follow up appointment is needed to review all lab and saliva test results. The follow up is not included in the cost of the saliva test. Office Hours Monday thru Thursday 9 AM to 5 PM (No after hour call). Payment Policy: Payment is due at the Time of Service. We accept Master Card, Visa, Checks, or Cash. We will obtain a credit card number from you when you make your appointment and your visit will be charged on the day of service. For office visits in Poulsbo your credit card will be billed one week prior to the appointment. Cancellation Policy: A 48 hour notice is required for all new patient appointment cancellations. Less than a 48 hour notice or failure to show up for your appointment will result in a $ charge for the appointment time. Insurance Information: (We Do Not Accept Insurance) Payment is due at the time of service by cash, check, master card, or visa. You will receive an itemized receipt. This will include all necessary insurance codes and information for self billing. Please consult with your individual insurance plan for correct self billing instructions and appropriate forms. It is advised to make copies of all forms prior to submitting insurance claims. Please be informed that Lynn Chadd is an Out of Network Provider/Non-Preferred Provider and is not contracted with any insurance companies. Medicare does not permit patients to self bill.

3 Medical History Intake Form - Men Name: Birth Date: Date form completed: Health Maintenance: Date of last Prostate examination Normal Abnormal Date of last PSA blood test Normal Abnormal Date of last colon cancer screening Normal Abnormal Date of last Diabetic Blood screening Normal Abnormal Date of last Cholesterol Blood screening Normal Abnormal Lifestyle: Do you smoke or use tobacco products now? No Yes If yes--how many per day? Have you smoked or used tobacco in the past? No Yes Do you drink alcohol? No Yes If yes, how much and how often How many caffeinated beverages do you drink a day? How many sodas do you drink per day? Do you exercise regularly? No Yes If so, what type and how often Do you practice any stress management techniques? No Yes If so, what and how often What type of work do you do? Nutrition: Describe your typical daily food intake: First Meal: Second Meal: Third Meal: Snacks

4 Medication Allergies: No Yes ( If yes please list) Medication Type of Reaction Medications: Medication Name Dose Times a day prescribed by: Please list supplements: Supplement Name Dosage Times of day Please attach a separate list if this is not enough space for your supplement list. Past Medical History (Please circle all that apply with additional explanation on the right). Heart Disease Stroke High Cholesterol High Blood Pressure Enlarged Prostate Urinary Problems Prostate Cancer Other Cancers Ulcers Thyroid Problems Blood clotting problems Respiratory Conditions Diabetes Arthritis Depression Anxiety Epilepsy Headaches/Migraines Visual problems Osteoporosis or Osteopenia Other:

5 Please List any surgeries you have had: Family History: Please circle all that apply and indicate your relationship: Prostate Cancer Maternal Paternal Colon Cancer Maternal Paternal Heart Disease Maternal Paternal Diabetes Maternal Paternal Osteoporosis Maternal Paternal Thyroid disorders Maternal Paternal Other Please circle all current symptoms you are experiencing: Hot Flashes Night Sweats Water Retention Bloating Weight Gain Decreased Sexual Desire Decreased Sexual Arousal Decreased Erectile Function Foggy Thinking Difficulty with Memory Muscle Weakness Decreased Muscle Size Decreased Stamina Hair Loss Fatigue Sleep Disturbance Depression Anxiety Mood Swings Irritability Headaches Snoring Sleep apnea or stop breathing while sleeping Dozing while seated or inactive Nodding off while driving Other: Please list any other concerns you would like to discuss during your appointment:

6 Client Provider Agreement I understand that Lynn A. Chadd, ARNP does not accept insurance as payment and that I am responsible for payment at the time of service. I have read and agree with the cancellation policy. I understand that if Medicare is my insurancei cannot self bill Medicare for reimbursement as per at the time of service. chronic problems, and treating hormone imbalance in men and women. I understand that Lynn Chadd does not provide after hour, urgent, emergency or on call care. I have been advised to have a Primary Care Provider for my general health care needs. I have been advised that in the event of an emergency I should dial 911 or go to my local emergency department. I have provided accurate medical history information on the Medical History Intake Form. Name: Birth date: Address: City: State: Zip Code: Please list any phone numbers where you would like to be contacted and/or messages left: Home Phone: Work Phone: Cell Phone: Address: We will use to deliver our newsletter, messages to you, and general correspondence. If you do not wish to receive reminders and messagesplease note below. Newsletter: Yes No Messages, reminders and general correspondence: Yes No Client Signature: Date: