Having come to Dr. Keesha for evaluation or treatment, I (or my authorized representative on my behalf) hereby consent to and authorize Dr. Keesha medical providers and other staff members involved in my care to administer such diagnostic procedures, treatment or both as they may consider advisable to maintain my health and to assess and to evaluate and treat my injury or illness. I understand that the provider responsible for my care has the responsibility to explain to me the purpose, the benefits and the most common risks involved in the diagnosis and treatment of my illness or injury, as well as alternative available courses of treatment, and I understand that I have the right to refuse any suggested examination, test or treatment.
Right to Refuse Treatment: In giving my general consent to treatment, I understand that I retain the right to refuse any particular examination, test, procedure, treatment, therapy or medication recommended or deemed medically necessary by my individual treating health care providers. I also understand that the practice of medicine is not an exact science and that no guarantees have been made to me as to the results of my evaluation and/or treatment.
I_______________________________,hereby authorize Dr. Keesha Ewers PhD,ARNP/Fern Life Center to charge my card on file for all office visits, supplements and testing. I have read this agreement and understand that I will be held fully responsible for its terms and charges and agree not to chargeback Dr. Keesha Ewers PhD, ARNP, Academy For Integrative Medicine or Fern LIfe Center as long as I have received the products and services that are defined within the terms of the invoice that I received. I also understand that Dr. Keesha Ewers PhD, ARNP is a pay at time of service provider, unless payment arrangements have been agreed upon.
It is our POLICY to have a credit card on file in our secure merchant services vault.
At Dr. Keesha Ewers, Ph.D., ARNP-FNP, IFM-CP, AAP-C, in order for us to provide you the most efficient healthcare and support on your wellness journey, we do not overbook our schedule. When you make an appointment with us, the time slot is guaranteed to you and no one else. Therefore, 48 hours notice is required to cancel an appointment in our office.
The Client will be Charged 100% of any visit not canceled within 48 hours to this office unless we are able to fill the spot. We confirm all appointments via email, text, and/or phone 2 days in advance – however, this is done strictly as a courtesy, and the responsibility of canceling an appointment remains with the patient.
Our promise to you: Our mission is to empower you to learn the patterns of behavior that inform your wellness choices. We promise to listen carefully, think deeply and kindle insight into directions ( therapies,treatments,services) that will nourish sustainable health. We promise to be considerate about your time and thoughtful regarding your finances. We thank you for allowing us to journey with you on this path to transformation and looking forward to growing with you.
We ask in return for your authenticity and courage to step outside of your usual thinking and behavorial patterns. A key component of success is the willingness to incorporate diet, lifestyle and relationship changes. We ask you to be honest with what are realistic changes to be begin with, and to wholeheartedly embrace the possibility that your health and life can look and feel exactly how you want it to, although this requires both effort and time and there are no guarantees from our clinic or providers that this will happen.
Our office is dedicated to protect the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee to ensure that your health information is never compromised is a principal concept of our practice. We may, from time to time, amend our privacy policies and practices but will always inform you of any changes that might affect your rights.
Protecting Your Personal Healthcare Information
Collection Protected Health Information
We will only request personal information needed to provide our standard of quality integrative medical care, implement payment activities, conduct normal medical practice operations and comply with the law. This may include your name, address, telephone numbers, social security number, employment data, medical history, health records, etc. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law.
Disclosure of our Protected Health Information
As stated above, we may disclose information as required by law. We are obligated to provide information to law enforcement and governmental officials under certain circumstances. We will not use your information for marketing purposes without your written consent. We may use and/or disclose your health information to communicate reminders about your appointments including voicemail messages, answering machines and emails.
You have a right to request copies of your healthcare information; to request copies in a variety of formats; and to request a list of instances in which we, or our business associates have disclosed your protected information for uses other than stated above. All such requests must be in writing. We may charge for your copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department of Health and Human Services.
We value you for being a patient at Dr. Keesha. Please let us know if you have any questions concerning your privacy rights and the protection of your personal health information.
Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect.
I acknowledge that I have been provided a copy of and have read and understand Dr. Keesha’s HIPAA Privacy Notice containing a complete description of my rights, and the permitted uses and disclosures, under HIPAA. While Dr. Keesha has reserved the right to change the terms of its Privacy Notice, copies of the Privacy Notice as amended are available from Dr. Keesha.
You have the right to revoke this authorization, in writing, at any time, except to the extent that Dr. Keesha has taken action in reliance on it. A revocation is effective upon receipt by Dr. Keesha of a written request to revoke and a copy of the executed authorization form to be revoked.
In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the person indicated below:
According to the Federal Food. Drug, and Cosmetic Act, as amended, Section 201(g)(1), the term drug is defined as an ”article intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease.“ Technically, vitamins, minerals} trace elements) amino acids, herbs, or homeopathic remedies are not classified as drugs. However, these substances can have significant effects on physiology and must be used rationally. In this office, we provide nutritional counseling and make individualized recommendations regarding the use of these substances in order to upgrade the quality of foods in a patient‘s diet and to supply nutrition to support the physiological and biomechanical processes of the human body. Although these products may also be suggested with a specific therapeutic purpose in mind, their use is chiefly designed to support given aspects of metabolic function. The use of nutritional supplements may be safely recommended for patients already using pharmaceutical medications (drugs), but some potentially harmful interactions may occur. For this reason, it is important to keep all of your healthcare providers fully informed about all medications and nutritional supplements, herbs, or hormones you may be taking.
You are under no obligation to purchase nutritional supplements at our clinic.
As a service to you, we make nutritional supplements available in our office. We purchase these products only from manufacturers who have gained our conﬁdence through considerable research and experience. We determine quality by considering: 1) the quality of the science behind the product; 2) the quality of the ingredients themselves; 3) the quality of the manufacturing process;and 4) the synergism among product components. The brands of supplements that we carry in our facility are those that meet our high standards and tend to produce predictable results.
While these supplements may come at a higher financial cost than those found on the shelves of pharmacies or health food stores, the value must also include assurance of their purity, quality, bioavailability (ability to be properly absorbed and utilized by the body), and effectiveness. The chief reason we make these products available is to ensure quality. You are not guaranteed the same level of quality when you purchase your supplements from the general marketplace. We are not suggesting that such products have no value; however, given the lack of stringent testing requirements for dietary supplements, product quality varies widely.
If you have concerns about this issue, please discuss them with our staff.
This questionnaire gives an indication of your toxicity and inflammation levels based on common signs and symptoms. Periodically, you may be asked to submit this questionnaire again to examine progress during and after treatments.
Interpreting your Grand Total score:
Check all the symptoms that are of concern to you at this time that you want to discuss with the practitioner. On the comments line, please indicate if any checked symptoms are current or past and describe any area in which you have experienced a severe episode and indicate if that episode was in previous 6 months or prior to 6 months ago.
Please take a few minutes to go inside of yourself to answer these last questions so that we may better design a program to fit your unique needs. Thank you for your careful consideration. It is very much appreciated.
Your form is ready to be submitted.