Please provide your insurance information below:
Please complete the attached records release form if applicable so that we may view lab results and other treatment details for better continuity of care.
Do you have any problems with any of the following body systems? If yes, please describe on the text box provided. The items in parentheses are only examples, please include your own/additional diagnoses as pertinent:
Do any members of your immediate family suffer from any of the following health conditions? If so, please explain in the text areas provided. Please specify which family member:
Do you use any of the following? Please indicate form and quantity per day or week.
In the past 7 days:
...hereby authorize Dr. Marinaro/Dr. Forman to perform the following specific procedures as necessary to facilitate my diagnosis and treatment:
Common diagnostic procedures: e.g., venipuncture, radiology, laboratory, X-ray
Minor office procedures: e.g., cleaning, dressing a wound, ear lavage, skin scraping
Medical use of nutrition: therapeutic nutrition, nutritional supplementation, and intramuscular vitamin injections.
Botanical medicine: plant substances may be prescribed as teas, alcohol-based tinctures, glycerites, capsules, tablets, creams or suppositories
Craniosacral Therapy, Visceral Manipulation: gentle forms of bodywork used to address back pain and other musculoskeletal complaints, headaches and organ dysfunction
Counseling: utilization of mental health counseling and techniques
Medical use of ozone: therapeutic ozone gas administered to isolated parts of the body, combined with depuration in an ozone sauna and injected subcutaneously or intramuscularly to address chronic pain and infections
I recognize the potential risk and benefits of these procedures as described below:
Potential risks: allergic reactions to prescribed herbs and supplements, side effects of medications or vaccinations, aggravation of pre-existing symptoms, discomfort, pain, infection, burns, nausea, light headedness, inconvenience of lifestyle changes, injury from injections, venipuncture or procedures. Please notify Dr. Marinaro/ Dr. Forman if you experience any symptoms which may be secondary to the above procedures.
Potential benefits: restoration of health and the body’s maximal functional capacity without the use of drugs or surgery, relief of pain and symptoms of disease, assistance in injury and disease recovery, and prevention of disease or it’s progression.
Notice to Pregnant Women: All female patients must alert the doctor if they know or suspect that they are pregnant as some of the therapies used could present a risk to the pregnancy.
With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by physician, or any personnel regarding cure or improvement of my condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time.
I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others unless so directed by myself or my representative or unless it is required by law. I understand that I may look at my medical record at any time and can request a copy of it by paying the appropriate fee. I understand that my medical record will be kept for a minimum of three, but no more than ten years after the last day of my visit. I understand that information from my medical record may be analyzed for research purposes, and that my identity will be protected and kept confidential. I understand that any questions I have will be answered by my practitioner to the best of his/her ability.
I understand that all sales of goods and services are final.
I request and authorize...
... to release healthcare information of the patient named above to:
Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human papilloma virus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea.
NENH patients, it is your responsibility to be aware of your insurance benefits, including coverage, co-pay, deductible, and maximums. Please call the number listed on the back of your insurance card and fill out the information below prior to your first appointment.
7. What is my co-pay or % covered for:
I acknowledge that the above listed coverage information is valid and correct. I understand that benefit verification is not a guarantee of coverage by my insurance company, and that I am financially responsible for all services rendered to me by any provider at New England Naturopathic Health. I authorize release of information in my medical history to my insurance company and assign all benefits for unpaid services to New England Naturopathic Health. This authorization will be considered valid unless revoked by me in writing.