Child New Patient Intake

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NEW PATIENT CHILD AND TEEN INTAKE FORM

 

 


















CHILDHOOD ILLNESSES




VACCINATION HISTORY


HOSPITAL VISITS, SURGERIES, IMAGING


ALLERGIES




FAMILY HISTORY


GENERAL INFO










For the following, please indicate if you have had or are experiencing now:













For the following, please indicate if you have had or are experiencing now:












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ELECTRONIC SIGNATURES
By checking the boxes below, your ELECTRONIC SIGNATURE stands for your personal signature and permission of the following items.

About the treatments you may receive

 

Dr. Yezman’s intention is to meet each patient’s needs, and address each person physically, spiritually, and mental-emotionally.  She has acquired a set of skills to address many different health issues.  These treatments and techniques include:

 

  • Physical exam, including general, musculoskeletal, EENT, heart and lung, orthopedic and neurological assessments.  One of more of these may be done to help evaluate your health issues further.  Dr. Yezman has done numerous physical exams and will do her best to make sure you are as comfortable as possible.

     

  • Evaluation of blood, urine, stool and saliva by means of labwork obtained from an outside source.  If you have labwork you want examined, please bring it in with you or complete the “Records Release” form on the Services and Form page of the website.

 

  • Soft tissue work such as muscle energy technique and strain- counterstrain. Dr. Yezman is experienced in soft tissue work and may use one of these techniques in combination with other methods.   Most forms of bodywork stimulate circulation to the areas treated.  This increases the body’s need for water and food.  Be sure to drink water and eat well on days you are treated.

 

  • Dietary advice and therapeutic nutrition:  including the use of foods, dietary plans, nutritional supplements and intra-muscular vitamin injections.   Dr. Yezman has extensive experience with finding a person’s own special balance in nutrition. 

 

  • Dr. Yezman carries an inventory of nutrient supplements, homeopathics, Western herbal medicines, and patented Chinese Medicine herbs.  If any are recommended for you, Dr. Yezman will explain why it is beneficial and how to take them.  Clear and detailed instructions will be given during the visit.

 

  • Hydrotherapy: includes the use of hot and cold water to improve the circulation of blood and lymph, and may include the use of gentle, safe levels of electrical current.   Depending on the type of current and how strong the stimulation is, this will alleviate pain, relax muscles, or decrease swelling.

     

  • Acupuncture, including but not limited to needle insertion in body, ear or scalp, moxa, electrical stimulation, acupressure. Dr. Yezman is experienced in a wide range of techniques and completes them as gently and safely as possible.

     

If you experience any symptoms after treatment to a degree that concerns you, you are encouraged to call and talk with Dr. Yezman, or be sure to mention it at your next visit.

 


Schedule

 

We respect your time and do not want you to wait too long in our waiting room.  We are usually on time, and ready to see you at your scheduled appointment time.  If we are going to be more than 10 minutes behind, we will try to reach you before your appointment to let you know.  In return, we ask that you arrive a few minutes before your appointment so you are ready at your scheduled appointment time. 

 

Dr. Yezman’s schedule can fill up in advance.  If you are on a treatment plan that requires repeated visits, we suggest that you schedule the treatments as far in advance as possible. 

 

Missed appointments

 

If you have an appointment you cannot keep, please call us as soon as possible.  We understand that schedules change and things come up.  We will gladly reschedule your appointment.  If you give us more than 48 hours notice, another patient will be happy to have your appointment slot.  Our office staff and other patients will appreciate this advanced notice. 

 

We understand that everyone makes mistakes and sometimes forgets an appointment.  We do not want to charge you for missed appointments.  We’d much rather see you!  However, to safeguard our schedule against repeated no-shows, we charge $75 for a missed appointment.  If a patient consistently cancels or misses appointments, we may ask that patient to seek out a different practitioner. 

 

Fees and financial responsibilities

 

We understand the need for information and predictability in the cost of care, so we provide the fee schedule to each patient.  We cannot guarantee a specific fee per visit, because each treatment session may vary in length, treatment and the services delivered.  The goal of the treatment plan, along with each treatment session, is to best solve the health issues that have brought you here. 

 

The most common initial visit consists of a very thorough and detailed Naturopathic medical intake. This includes an intake, examination, review of labwork or other medical information and a treatment plan. The cost for this initial visit is $250, and is an one and a half hour appointment.

Follow up Naturopathic consultation appointments are $150. 


New patient acupuncture only appointments are one hour long and include intake, examination, acupuncture and treatment plan.  The cost for this is $150, and follow up appointments are $100. 

 

 

New Patient Comprehensive Naturopathic intake, interview, exam, and creation of treatment plan: $250

Established patient Naturopathic consultation: $150

New Patient Acupuncture appointment: $150

Established patient Acupuncture: $100

Vitamin Injections: $35-75 

Hydrotherapy treatment: $45

Hot/cold poultice: $15

Local massage: $20

Complete certified physical exam: $150

Nutritional supplements: costs vary
































Insurance Billing

 

 

Dr. Yezman is not in-network with any insurance plans, HMOs, or PPOs.  You must have out-of-network benefits in order for your insurance to cover Dr. Yezman’s treatments.

 

Nutrient supplements, homeopathics and herbs must be paid for by the patient.

 

No matter what type of insurance you are using, you are responsible for the fees for your treatment.  If the insurance company denies payment, you are responsible for paying the fees in full.  If the insurance company pays only part of the fees, you are responsible for paying the balance. 

 

If you do not understand any of these policies, please ask and we will discuss them before you sign below. 

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Consent to Examination and Treatment


 

Your safety and comfort are of the greatest importance to Dr. Yezman.  Be assured that no technique will be performed or treatment delivered without your full consent and participation.  To assure us that you consent to examination and treatment, we respectfully ask you to read these pages and sign at the bottom. 

 

If you do not understand any of this information, or if you cannot agree to sign this page, please tell Dr. Yezman about your specific concerns. 

 

 1. Your treatment may consist of one or more of the following:
  • Physical exam, including general, musculoskeletal, EENT, heart and lung, orthopedic and neurological assessments.  This can be used for school or employment evaluations, and will give us a general idea of your health.

  • Evaluation of blood, urine, stool and saliva by means of labwork obtained from an outside source.

  • Soft tissue work such as muscle energy technique and strain- counterstrain

  • Dietary advice and therapeutic nutrition, including use of foods, diet plans, nutritional supplements and intra-muscular vitamin injections

  • Botanical/ herbal medicines, and patented Chinese Medicine herbs, prescribing of various therapeutic substances including plant, mineral, and animal materials. Substances may be given in the forms of teas, pills, creams, powders, tinctures which may contain alcohol, suppositories, topical creams, pastes, plasters, washes or other forms

  •  Homeopathic remedies (highly diluted quantities of naturally occurring substances)

  • Hydrotherapy (use of hot and cold water, may include transcutaneous electrode stimulation)

  • Counseling, including but not limited to visualization for improved lifestyle strategies

  • Acupuncture, including but not limited to needle insertion in body, ear or scalp, moxa, electrical stimulation, acupressure


 

2. Your treatment may require you to change into a gown and/or shorts.  These garments are designed to allow you to move freely and will allow Dr. Yezman to access your skin while preserving your comfort and modesty.  Your comfort and relaxation are of the greatest importance, so please notify Dr. Yezman if you are cold or if you do not feel adequately covered.


3. Your treatment may require Dr. Yezman to contact areas all over your body.  Let us know of any specific concerns you have.  By signing below, you are indicating that you give Dr. Yezman permission to examine and treat any area that is necessary.

 

4. Your health issues will always be discussed and explained with you.  While the risk of complications or side effects from any treatments is rare, at times they do occur. The most common may include, but are not limited to, soreness, bruising, itching, burns, and temporary worsening of symptoms.   By signing below, you are indicating that yo understand and accept these risks.

 

5. Dr. Yezman will recommend as part of your treatment plan specific exercises, nutritional supplements, homeopathics and/or herbs.  You are responsible for following the instructions, and for following through with the recommendations made.  Please ask Dr. Yezman any specific questions you have about your treatment plan. 


6. After the initial interview and examination, Dr. Yezman will do her best to describe your condition and a plan for treatment.  You are not obligated to receive treatment.  If at any time during treatment you have concerns about the course of your care, the techniques being used, or if new symptoms arise, tell Dr. Yezman about your concerns or new symptoms.  They may contain important information about your health and wellness.   



7. As the patient, you are always allowed to decline treatment.  No matter the issue.




HEALTH INFORMATION PRIVACY 

Consent for Purposes of Treatment, Payment and Healthcare Operations for Patients

 

We are required by federal law (HIPAA) to have your signature on this form.  It describes how we can and cannot use your information.

 

I consent to the use or disclosure of my protected health information by Dr. Nicole Yezman for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care.  I understand that diagnosis or treatment of me by Dr. Yezman may be conditioned upon my consent as evidenced by my signature on this document. 

 

I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice.  Dr. Nicole Yezman is not required to agree to the restrictions that I may request.  However, if dr. Yezman agrees to a restriction that I request, the restriction is binding on Dr. Yezman’s office. 

 

I have the right to revoke this consent, in writing, at any time, except to the extent that Dr. Yezman has taken action in reliance on this consent.

 

My “protected health information” means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse.  This protected health information relates to my psat, present or future physical or mental health or condition and identifies me, or ther is a reasonable basis to believe the information may identify me.

 

At times. Dr. Yezman uses Lottie Mackey for insurance billing services; I understand this and do hereby give my consent to have my insurance information processed by this company.

 

I understand I have a right to review Dr. Yezman’s Notice of Privacy Practices prior to signing this document.  Dr. Yezman’s Notice of Privacy Practices has been provided to me.  The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Dr. Yezman’s office.  This Notice of Privacy Practices also describes my rights and Dr. Yezman’s office’s duties with respect to my protected health information. 


Dr. Yezman’s office reserves the right to change the privacy practices that are described in the Notice of Privacy Practices.  I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment. 


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Consent to Arbitration

 

When you come in for your initial visit, you will be asked to sign an arbitration agreement.  By signing this agreement we are agreeing that any dispute arising out of the medical services you receive from Dr. Nicole Yezman of the Clinic Of Natural Health, is to be resolved in binding arbitration rather than a suit in court.  Lawsuits are something that no on anticipates and everyone hopes to avoid.  We believe that the method of resolving disputes by arbitration is one of the fairest systems for both patients and physicians.  Arbitration agreements between health care providers and their patients have long been recognized and approved by Oregon and Michigan courts.

 

            By signing this agreement you are changing the place where your claim will be presented, if ever there is one.  You still can call witnesses and present evidence.  Each party selects an arbitrator (party arbitrators), who then select a third, neutral arbitrator.  This agreement generally helps to limit the legal costs for both patients and physicians, because the time to conduct an arbitration hearing is far less than for a jury trial.  Further, both parties are spared some of the rigors of trial and the publicity which may accompany judicial proceedings.  This arbitration agreement enables Dr. Yezman to provide you with more affordable healthcare.

 

            Our goal, of course, is to provide you with quality medical care which fully meets your health care needs.  We know that most problems begin with communication, this has been proven time and time again. Therefore, if you have any questions about your care, please ask, we are open to discuss and problem solve any concerns you may have. 

 

I agree to the terms and conditions listed above.