Pediatric Intake Paperwork

Pediatric Intake Paperwork
Child's Legal Name*

First Name Last Name
Child's Birth Sex*
Child's Preferred Pronoun*
Today's Date*

MonthDay Year
Date
Legal Guardian's Full Name*

First Name Last Name
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
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*
Child's Date of Birth:*

MonthDay Year
Date
Child's Social Security Number*
Your Occupation*
Your Employer*
Whom to contact in case of emergency? (please list relation and best contact number)*
Personal Medical History
Please list complaints for your child in order of priority: *
Please list any allergies and reactions to medicines or foods your child has:*

Please list pharmaceutical medicines your child takes, along with the dose: *

	Medication name	Dose	Frequency (how often you take medication)
1
2
3
4

Please list any health supplements your child takes, along with the dose: *

	Health Supplement name	Dose	Frequency (how often you take medication)
1
2
3
4

Please list any major illnesses, accidents or hospitalizations your child has experienced including dates:*
Preferred pharmacy (name and address): *
Child's pediatrician (name and address): *
Date of your child's last physical exam:*

MonthDay Year
Date
Any abnormal results?*
Date of your child's last blood work:*

MonthDay Year
Date
Any abnormal results?*

Family Medical History
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:
Heart Disease/High Blood Pressure/High Cholesterol:*
Diabetes:*
Cancer: Type?*
Alcoholism/Drug Addiction:*
Mental Health Disorder: Type?*
Asthma/Respiratory Issues:*
COPD:*
Stroke:*
Liver Disease:*
Kidney Disease:*
Digestive Issue or Diagnosis:*
Arthritis*
Vision Problems:*
Any other serious health conditions?*
Does your child have any problems with any of the following body systems?
EENT (head, ears, eyes, nose, throat)
Endocrine (thyroid or another hormone imbalance)
Nervous system (dizziness, imbalance, slow thinking, poor memory)
Respiratory (allergies, asthma, chronic cough)
Skin (psoriasis, eczema, acne)
Cardiovascular (heart palpitations, chest pains, colds hands and feet, varicose veins)
Digestive (GERD, heartburn, nausea, constipation, diarrhea, gas, bloating)
Musculoskeletal (chronic back or limb pain)
Psychological (anxiety, depression)

Lifestyle

Please provide examples of typical meals:*

	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. Froman to perform the following specific
procedures as necessary to facilitate my child’s diagnosis and treatment:

Common diagnostic procedures: e.g., venipuncture, radiology, laboratory, X-ray, paps

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

Counseling: utilization of mental health counseling and techniques

Medical use of Ozone Therapy: 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. Froman 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 seven years, 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. Refunds for supplements up to 90 days after purchase (unopened items only).
Signature of Legal Guardian

Clear
Date*

MonthDay Year
Date

Integrative Concierge Care Policies

Please read and initial the following statements below and sign/date at the bottom
I agree to utilize Integrative Concierge Care during the business hours of New England Naturopathic Health, currently 8 AM - 4 PM Monday, Tuesday, Thursday, and Friday. NENH agrees to respond to messages within 48 hours, excluding holiday weekends.*
I agree to maintain a relationship with a primary care doctor for insurance purposes and for emergent needs that cannot be addressed by NENH. Please note that NENH will not accept any patient without a primary care doctor and should a potential patient not have one, NENH can provide a referral to an integrative PCP.*
I understand that diagnostics, supplements and medications are not included in the price of my subscription.*
I understand that it is my responsibility to request Superbills from NENH for submission to insurance for reimbursement of out-of-pocket costs and to ensure insurance coverage of any diagnostic testing prior to undergoing the testing.*
I agree to have my chosen form of payment (checking account, debit card, Health Savings Account or credit card) debited once monthly for the price of my subscription. I understand that a declined payment will result in an additional $25 charge and that I must update my payment source immediately. Should the payment be declined again after 1 week’s time, the charge will increase to $50. Should the payment be declined a third time, the patient will be required to pay in advance for the remainder of their annual subscription.*
I understand that Integrative Concierge Care requires a minimum one year commitment, from the time that the plan is established, and at the end of the year I will have the option to change subscriptions or discontinue care. The plan will automatically renew on the anniversary of the start date. Patients will have a 60 day timeframe and no less than 72 hours prior to renew, change, or discontinue the subscription.*
I understand that, should I desire to terminate my Concierge Care subscription before the end of the one year minimum commitment, I will be assessed an administrative charge of two months of the chosen subscription.*
I understand that for the efficiency of patient care, I must have a basic knowledge of electronic communications and an internet speed that can accommodate video telehealth appointments if I elect this option for my appointment. Please see Zoom’s website for internet speed requirements. (https://support.zoom.us/hc/en-us/articles/201362023-System-Requirements-for-PC-Mac-and-Linux)*
I understand that I am responsible for scheduling and rescheduling my own appointments through the Charm patient portal and must cancel any appointment that I am unable to attend at least 48 hours prior to the appointment. Should I fail to cancel the appointment without a demonstrated emergency, I will be assessed a $50 no-show charge to the stored payment source. I understand that should I arrive more than 10 minutes late for a scheduled appointment without a demonstrated emergency, the appointment may be rescheduled and I will be assessed the $50 late cancellation charge.
I understand that the Charm Patient Portal is the primary means utilized by NENH for communication with its patients and agree to use the portal to reach NENH staff. I understand that email is not HIPAA compliant and cannot be used in a medical setting. Emails containing medical questions or information will be redirected to the Charm portal and will be counted toward total message allotment. I understand that phone messages will be checked once daily on business days only and that phone calls will count toward total message allotment.
I understand that for effectiveness of treatment, new or acute complaints cannot be treated through the patient portal and that an appointment will be scheduled at Dr Marinaro’s discretion for assessment and treatment of new complaints.
I understand that should I require further appointments or messaging than my concierge subscription includes, extra appointments and messages can be added to the plan as needed at the individual prices of $115/acute appointment of 15-20 minutes, $225/follow up appointment of 45 minutes and $25/message.
I understand that messages requesting refills or clarifying laboratory testing procedures will not count toward my allotment of messaging.
Name

First Name Last Name
Signature

Clear
Should be Empty:

Pediatric Intake Paperwork

Personal Medical History

Family Medical History

Lifestyle

Terms of Consent for Care

Integrative Concierge Care Policies