Download The Natural Medicine Clinic

1
Dear _______________________ ,
It was a pleasure talking to you and I look forward to being a partner on the journey for
vibrant health for you and your family.
I have attached (included) some forms that we will review at your first phone or Skype
appointment. Your detailed and thoughtful responses will help us to utilize our time more
effectively. Please email these forms at least 48 hours before your first visit. Your first
visit will be a thorough assessment of your health and you should allow 1-2 hours for this
visit.
If you are unable to keep your scheduled appointment time, _______________________
please let us know as soon as possible so that we may allow another patient to have your
appointment. Please provide at least 24 hours notice of cancellation as a courtesy, as we do
not double book and have reserved this time especially for you. Our policy is a $100.00
charge for missed initial appointment and $50 for missed follow up appointment without
adequate notice (less than 24 hours). If you do not give any notice, the full amount will be
billed. Please help us to serve you better by keeping scheduled appointments. Payment is
expected at the time of your visit, and we take cash, check, VISA, or Mastercard.
Please remember to bring in copies of any recent lab work or medical records as well as
the supplements or medications you are currently taking.
I look forward to seeing you and working together for your optimal health!
Yours in health,
Amber Golshani, ND
Natural Health Consultant
www.drambergolshani.com
1-877-627-5507
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Pediatric Intake Form
Full Name______________________________ Date of birth _________ Sex M or F
Address: ______________________________________________________________
City:______________________________State:_______________Zip:_____________
Mother’s Full Name and occupation:________________________________________
Father’s Name and occupation:_____________________________________________
Phone Number:____________________________________________________
Parents are (circle): Married Separated Divorced Living Together Other
Parents Email Address:_____________________________Recieve E-News? Y or N
Regular Pediatrician name and city located in:__________________________________
Reason for Office Visit:____________________________________________________
Has child been seen by any other doctor(s) for this complaint? Yes No Past
Has child had any blood work done? If yes, please list what:
___________________________________________________________________
Please list any operations or hospitalizations and year occurred:
1.
2.
3.
Please list all medicines (drugstore or prescription) child is on, dose and for how long?
1.
2.
3.
4.
Please list all supplements child is taking, dose and for how long?
1.
2.
3.
4.
Please list any other Doctors/Therapists/Healers child is seeing and for what reason?
___________________________________________________________________________
_____________________________________________________________________
Previous medical history
Yes indicates the child gets the problem regularly; No indicates the child never had the
problem; Past indicates the child had the problem in the past but not recently. Please circle
the correct one for your child.
Ear Infections? Yes
No
Past
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If has had, how many total?__________
Colds? Yes No Past
If has had, how many total? __________
Strept throat? Yes No Past
If has had, how many total?__________
How many times has the child taken antibiotics:________________
What other medicines has the child taken? And how often?
1.
2.
3.
4.
Hearing tests Normal: Yes No Not Tested
Vision Tests Normal: Yes No Not Tested
Any speech impediments: Yes No Past
Learning impediments: Yes No Don’t know
Vaccination History: Yes, has had; No, has not; Some, did not finish all shots
MMR: Yes No Some
DPT: Yes No Some
Hep B: Yes No Some
Hib:
Yes No Some
Chickenpox: Yes No Some
Polio: Yes No Some
Other:_____________________________
Any reactions to vaccinations? If so, please explain: _______________________
__________________________________________________________________
Family history
Allergies: Yes No
Cancer:
Yes No
Cardiovascular disease: Yes No
Diabetes mellitus:
Yes No
Obesity:
Yes No
Tuberculosis: Yes No
Mental Illness: Yes No
Mother’s Pregnancy history
Age at conception:_________
Did she have other children already? Yes No
Health During Pregnancy:
Mothers emotions during pregnancy_________________________________________
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Smoking: Yes No
Diabetes: Yes No
Coffee:
Yes No
Nausea/Vomiting: Yes No
Recreational drugs: Yes No
Emotional Stress: Yes No
Preeclampsia: Yes No
Length of Labor:__________
Vaginal birth: Yes No
Traumatic birth: Yes No
If the birth was difficult, please explain:
_______________________________________________________________________
Health of baby at birth:_____________________________________________________
Child breastfed: Yes No
For how long:______________
When put on formula:______________
What formula was used:_________
When was child put on solid food:____________________
When did child Walk:___________________
Talk:________________
Develop Teeth:________________________
Health History of child
Jaundice as baby:
Cradle cap:
Eczema or psoriasis:
Diarrhea:
Constipation:
Finicky eating:
Poor teeth:
Chronic sniffles:
Bad foot odor:
Very sweaty baby/child:
Hyperactivity:
Growing pains:
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Colic:
Yes
Anemia:
Yes
Asthma:
Yes
Warts:
Yes
Nightmares:
Yes
Bed-wetting: Yes
Tantrums:
Yes
Disobedient:
Yes
Fears/Phobia: Yes
Diaper Rash:
Yes
Early Puberty: Yes
Stomach aches: Yes
No
No
No
No
No
No
No
No
No
No
No
No
Any particular household stressors child has witnessed or gone through:
1.____________________________________________________________________
2.____________________________________________________________________
3.___________________________________________________________________
Known Allergies to Food, Medicines, Pollens, Dander, etc.:
______________________________________________________________________
Typical Day’s Diet:
Breakfast:______________________________________________________________
Snack:_________________________________________________________________
Lunch:_________________________________________________________________
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Snack:_________________________________________________________________
Supper:________________________________________________________________
Snack:_________________________________________________________________
Sleep:
Does your child nap? If so for how long?______________________________________
Time to bed at night?_________________ Time of waking in morning?_____________
Does child wake at night? If so, why?_________________________________________
Toxin Exposure:
Has the child ever lived near a refinery or other highly polluted area?_______________
Has the child ever lived in a house with lead paint?______________________________
Has the child ever lived in a house that had new paint, cabinets, carpeting installed and did
that seem to affect their health at all?______________________________________
Do you spray pesticides or herbicides around the house or use other toxic chemicals?
______________________________________________________________________
Does the child seem particularly sensitive to perfumes or other vapors?_____________
Social History
Siblings name and ages___________________________________________________
How is your child with friends?_____________________________________________
Meeting new people or situations?___________________________________________
In three words, my child is__________________________________________________
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Informed Consent for Treatment
I, as a patient, have the right to be informed about my condition and recommended care.
This disclosure is to help me become better informed so that I may make the decision to give,
or withhold, my consent as to whether or not to undergo care having had the opportunity to
discuss the potential benefits, risks, and hazards involved.
I, _______________________, hereby request and consent (or for the patient named the
below for whom I am legally responsible) to examination and treatment with naturopathic
medicine by Amber Golshani, N.D. and/or other naturopathic physicians or students training
at the office. I can request students and preceptors not be included in my evaluation.
I understand that I have the right to ask questions and discuss to my satisfaction with Amber
Golshani, N.D.:
1. my suspected diagnosis or condition
2. the nature, purpose and potential benefits of the proposed care
3. the inherent risks, complication, potential hazards, or side effects of treatment or
procedure
4. the probability or likelihood of success
5. reasonable available alternatives to the proposed treatment or procedure
6. the possible consequences if treatment or advice is not followed and/or nothing is
done.
I understand that naturopathic evaluation and treatment may include, but is not limited to:
Physical exam: e.g. general, musculoskeletal, cardiovascular, gynecological, abdominal,
respiratory.
Common diagnostic procedures: laboratory evaluation of blood, urine, stool and saliva
Dietary advice and therapeutic nutrition: use of foods, diet plans, nutritional
supplementation.
Botanical medicine: botanical substances may be prescribed as teas, alcoholic tinctures,
capsules, tablets, creams, powders, plasters, washes or suppositories.
Homeopathic medicine: the use of highly dilute quantities of naturally occurring plants,
animals and minerals to gently stimulate the body’s healing responses.
Lifestyle counseling and hygiene: diet therapy, promotion of wellness including
recommendations for exercise, sleep, stress reduction and balancing of work and social
activities.
Psychological counseling: mind-body spirit techniques and basic counseling interactions
including but not limited to guided imagery, visualization, relaxation response, breathing
exercises
Hydrotherapies: use of hot and cold water e.g., hydrocolator, contrast treatments, wet sheet
wrap.
Soft tissue manipulation: massage, neuro-muscular technique, muscle energy stretching.
________ (Initial Here)
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I recognize the potential risks and benefits of these procedures as described below:
Potential risks: allergic reactions to prescribed herbs and supplements and prescription
medications; side effects of natural medications, inconvenience of lifestyle changes, injury
from procedures or soft tissue manipulation; an aggravation of pre-existing symptoms.
Potential benefits: restoration of the body’s maximal functioning capacity, relief of pain and
symptoms of disease, assistance in injury and disease recovery, and prevention of disease or
its 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.
Notice of individuals with bleeding disorders, pace makers and cancer. For your safety,
it is important to alert the provider of these conditions.
Please initial on each line below:
____ I understand Dr. Golshani is not licensed by the state of Maryland to practice
naturopathic medicine. There is not currently a naturopathic license available in Maryland.
The use of the word doctor reflects Golshani’s level of training (doctorate of naturopathic
medicine), and the practice of naturopathic medicine is not specifically regulated by the state
of MD. Golshani is a Vermont licensed naturopathic physician, in order to indicate that the
training requirements and continuing education requirements for naturopathic practice are
upheld.
_____I understand the U.S. Food and Drug Administration has not evaluated or approved
nutritional, herbal and homeopathic supplements, and therefore should not be taken as such.
However, they have been widely used in Europe, China and the U.S.A for years.
____ I understand that (as with drugs) nutritional supplements, herbal and homeopathic
remedies may exhibit some side effects in certain sensitive individuals, may interact with
certain allopathic medications or lab tests, or show symptoms due to certain pre-existing
disease conditions.
_____I understand that it is not being recommended to me to discontinue any other
treatment or care being provided by any other health care professional. I understand Dr.
Golshani does not function as a primary care physician, and that she offers her services in
addition to other services I receive. I understand she does not replace the
services of my primary care physician. The consultee(s) understand(s) that Dr. Golshani
cannot manage the overall care of the person for whom the consultation is occurring, and it is
my responsibility to seek conventional medical care for my health concerns.
______I understand that if I refuse to seek conventional medical care for my condition, this
refusal of care is directly against the advice of Dr. Golshani.
________ (Initial Here)
www.drambergolshani.com
1-877-627-5507
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____ I understand that Dr. Golshani is not licensed to prescribe any controlled substances.
____ I understand that Dr. Golshani will only prescribe medications (natural or over the
counter) if she thinks it is in the best interest of the patient. Appropriate referrals will be
provided to manage the patient’s prescriptive medication needs.
____ I understand that Dr. Golshani is not a psychologist or psychiatrist. Counseling
services are for the improved lifestyle strategies and wellness.
____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. Exceptions to confidentiality are:
danger to yourself; danger to another; or child abuse. The privileged nature of our
communication ceases under these circumstances. 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
my medical record will be kept for a minimum of three, but no more than ten years after the
date of my last 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 have been diagnosed by a medical doctor with___________________________
_______________________________________________________________________
____ My primary care physician is___________________________________________
________________________________________________________________________
Phone number____________________________________________________________
______I understand I will discuss all my prescription medication questions and changes with
my conventionally trained doctor , and that naturopathic remedies do not replace that
conventional advice.
________I understand that there are risks associated with disease, and there are risks
associated with not treating my condition or disease with conventional medicines.
________I do not expect the doctor to be able to anticipate and explain all risks and
complications, and I wish to rely on the doctor to exercise all judgment in recommending the
treatments that the doctor feels at the time, based on the facts then known, is in my best
interest. I also understand that it is my responsibility to request that the provider explain
therapies and procedures to my satisfaction.
I further acknowledge that no guarantees or services have been made to me concerning the
results intended for the treatment.
________ (Initial Here)
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1-877-627-5507
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By signing below I acknowledge I have been provided ample opportunity to read this form or
that it has been read to me. I understand the above and give my oral and written consent to
the evaluation and treatment. I intend this consent form to cover the entire course of
treatments for my present condition and any future conditions for which I am seeking
treatment.
I understand that full disclosure of information has been made to me and all my questions
have been answered to my full satisfaction. I understand that I am free to withdraw my
consent and to discontinue participation in these procedures at any time.
Print Patient Name:
________________________________________________
Signature of Patient __________________________________________________
Date: _____________
Print Guardian’s Name: _______________________________________________
Signature of Patient Representative or Guardian :____________________________
Date: ____________
Provider: Amber Golshani, ND
Initials: _____________________
Date: ____________________________
Original to: Chart Copy to: Patient (if requested)
Form revised: 7/24/07
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Dr. Amber M. Golshani
Client Financial Agreement
Initial Consultation
Adult Platinum Level Comprehensive Care (up to 2 hours)
Adult Gold Level Focused Care (up to 1 hour)
Adolescent (4-17 years old) (up to 1.5 hour)
Child (< 4) (up to 1 hour), New Patient Acute Illness
$ 497
$ 247
$ 377
$ 247
Follow-up Consultation (in person or by phone)
Standard
Brief
5 Follow Up Package (5 standard visits for price of 4)
Laboratory Fees and Supplements
$ 127
$ 67
$ 508 paid in full
Vary
Phone Questions/Consultations:
We would prefer that people call with questions rather than leave them unanswered. There is no charge for
any call to clarify instructions given at a previous visit. Questions and consultations that cover new
material, require new information, or take an extensive amount of time to answer are essentially substitutes
for office visits. These will be billed at a minimum of $35, and may be billed at the same rate as the visit
for which they substitute. For example, a call that substitutes for a limited visit will be billed at $127.
Laboratory Fees and Supplements
Dr. Golshani may recommend laboratory testing or nutritional, herbal, or homeopathic supplements which
will be billed at an additional cost. You will be told in advance of their cost; however you are under no
obligation to purchase these products and/or services through Dr. Golshani. Alternate sources can be
recommended at your request.
Cancellations:
If you are not able to keep your scheduled appointment, please notify us at least 24 hrs in advance of the
appointment. There is no charge if an appointment is cancelled with a minimum of 24 hrs notice. An
appointment cancelled with less than 24 hrs noticed does not allow enough time for other interested
patients to be scheduled and is a great inconvenience for our office. Thus, there is a $50 charge for a follow
up and a $100 charge for a new patient visit. Full service fees will be charged if no notice is received.
Changes in Service Fees:
Service Fees are subject to change. You will be provided a minimum of 30 days notice of any changes to
our service fees.
Payments:
Payment is expected at the time of service. I accept cash, check, VISA, or Mastercard. We are sensitive
to those with special financial needs and will consider a sliding scale for qualified individuals. Open
accounts will be charged an interest rate of 15% per month after the first 30 days. Bounced checks fee is
$25 and no further checks will be accepted.
Agreement:
Dr. Golshani is committed to providing quality care for your whole family. We appreciate your patronage.
I, __________________________________ agree to the above defined financial policies. In the case of
default of payment, I am responsible for full payment of the balance, interest accrued, and any collection
costs and legal fees incurred to collect on this account. I, the undersigned, have read, understand, and
accept the information and conditions specified in this document.
___________________________________________________________ _____________________
Client (or Parent/Guardian) Signature
Date
Dr. Amber Golshani 5 Federal Street, Suite 310 Easton, MD 21601
1-877-627-5507
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Patient-Provider E-Mail Agreement
E-mail offers an easy and convenient way for patients and doctors to communicate. In
many circumstances, it has advantages over office visits or telephone calls. But
remember, there are important differences. E-mail is not the same as calling the office;
there is no person at the other end of the e-mail – just a computer. You can’t tell for
certain when your message will be read or even if the doctor is in the office or on
vacation.
Nonetheless, we believe that the ease of communication e-mail affords is a benefit to
patient care. It will further assist us if you could identify the nature of your request in the
subject line of your message. Below are our rules for contacting us via e-mail.
• E-mail is never appropriate for urgent or emergency problems! Please use the
telephone or go to the Emergency Room for emergencies.
• E-mail is great for asking those little questions that don’t require a lot of discussion.
• E-mail should not be used to communicate sensitive medical information, such as
information regarding sexually transmitted diseases, AIDS/HIV, mental health,
developmental disability, or substance abuse.
• E-mail is not confidential! It is like sending a postcard through the mail. You should
know that if sending e-mails from work, your employer has a legal right to read
your e-mail if he or she chooses.
• E-mail may become part of the medical record when we use it; a copy may be
printed and placed in your chart.
• E-mail is not a substitute for seeing your physician. If you think that you
need to be seen, please call and schedule an appointment!
Finally either party can revoke permission to use the e-mail system at any time.
I DO want to communicate with my doctor electronically. I have read the above
information and understand the limitations of security on information transmitted.
Patient Name: _________________________
Patient Signature: ______________________
E-mail Address: _________________________
Date: __________
Dr. Amber Golshani 5 Federal Street, Suite 310 Easton, MD 21601
1-877-627-5507