Pediatric Intake Paperwork

Pediatric Intake Paperwork
Child's Full Name *

First Name Last Name
Date *

Month Day Year
Date
Date of Birth: *

Month Day Year
Date

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Cell Phone *

Area Code Phone Number
Work Phone *

Area Code Phone Number
Home Phone *

Area Code Phone Number
Email *
example@example.com
Preferred Method of Contact *
Social Security Number *
Your Occupation *
Your Employer *
Whom to contact in case of emergency? (please list relation and best contact number) *
Please provide your insurance information below:
Primary Insurance Company *
Group #: *
Member ID#: *
Relationship to Subscriber *

Claims Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Subscriber Name (if other than patient) *

First Name Last Name
DOB: *

Month Day Year
Date
Secondary Insurance Company *
Group #: *
Member ID#: *
Relationship to Subscriber *

Claims Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Subscriber Name (if other than patient) *

First Name Last Name
DOB: *

Month Day Year
Date

Personal Medical History
Who is your child's Physician? *
Please list complaints for your child in order of priority: *
Please list any allergies to medicine or foods and include the type of reaction (for example, anaphylaxis, stomach upset, rash, etc.): *

Please list pharmaceutical medicines you take, along with the dose: *

Medication name

Dose

Frequency (how often you take medication)

Please list any health supplements you take, along with the dose: *

Health Supplement name

Dose

Frequency (how often you take medication)

Please list any major illnesses, accidents or hospitalizations including dates: *
Date of your last physical exam: *

Month Day Year
Date
Any abnormal results? *
Date of your last blood work: *

Month Day Year
Date
Any abnormal results? *

Lifestyle

Daily Diet *

Please Provide examples of typical meals

Breakfast

Lunch

Dinner

Snacks

How much water does your child drink in a day? *
Does your child exercise? If so, please list types and amount per week: *
Are there any problems with sleep? How many hours does your child typically sleep in a night? *
Please list your health goals for your child in order of priority: *

Terms of Consent for Care
I... *

First Name Last Name
...hereby authorize Dr. Marinaro/Dr. Hayford 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

Homeopathic medicine: the use of highly dilute quantities of naturally occurring plants, animals and minerals

Craniosacral Therapy, Visceral Manipulation: gentle forms of bodywork used to address back pain and other musculoskeletal complaints, headaches and organ dysfunction

Medical use of Ozone Therapy: use of ozone/oxygen gas to treat skin conditions, infections, allergies and GI conditions. Ozone may also be used as an intra-muscular injection (Prolozone therapy) to decrease pain in a muscle or tendon and help to heal injuries.

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. Hayford 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.
Signature *

Clear
Date *

Month Day Year
Date

New England Naturopathic Health Policies

Please initial in the following boxes:
I understand that payment of consultation fees, lab fees, supplements and any other services are due at the time of service. *
I understand that phone consultations and phone lab reviews with Dr. Marinaro/Dr. Hayford will be billed at the same rate as an in-office visit *
I understand that I may message Dr. Marinaro’s/Dr. Hayford’s support staff through Patient Fusion. Email is not an acceptable communication format due to confidentiality concerns. *
I understand that any supplements purchased at NENH or via Health Wave (per NENH request) cannot be returned once opened. *
I understand that if I am more than ten minutes late for an appointment. I may not be seen and may be assessed a cancellation fee. *
I understand that should I miss an appointment or cancel with less than a twenty-four hours’ notice, I will be assessed a cancellation fee. *

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
Patient's Name:

First Name Last Name
Date of Birth:

Month Day Year
Date
Previous Name:

First Name Last Name
Social Security #:
I request and authorize...
... to release healthcare information of the patient named above to:
Office Name:
Fax Number:
Requesting documentation regarding:

Healthcare information relating to the following treatment, condition, or dates: Labs and Imaging only Other
Specify treatment, condition or dates:
Specify other:
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, ymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea.
I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.

Yes No
I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above.

Yes No
Patient Signature:

Clear
Date signed:

Month Day Year
Date
THIS AUTHORIZATION EXPIRES ONE YEAR AFTER IT IS SIGNED.

INSURANCE BENEFITS VERIFICATION

Please ensure this form is completed and submitted prior to your first appointment. Please allow 1 hour to complete this form.
Patient Information
Full Name

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone #

Area Code Phone Number
Date of Birth

Month Day Year
Date
Insured Information
Full Name

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone #

Area Code Phone Number
Company
Date of Birth

Month Day Year
Date
Relationship to Insured
Insurance Company Information
Name
Phone #

Area Code Phone Number
ID #
Group #
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.

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.
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

Pediatric Intake Paperwork

Personal Medical History

Family Medical History

Lifestyle

Terms of Consent for Care

New England Naturopathic Health Policies

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

INSURANCE BENEFITS VERIFICATION

Patient Information

Insured Information

Insurance Company Information

Questions For Your Insurance