Medication/Supplement List
(Must be completed prior to each appointment)
Patient Name:
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First Name
Middle Name
Last Name
Date of Birth:
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Month
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Day
Year
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Medication/Supplement Name
Medication/Supplement Brand (if known)
Dosing Per Serving (g, mg, mcg)
How Many Servings Daily (once, twice, etc.)
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Provider and Office Guidelines
Initial and submit 72 hours prior to appointment
Initial
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All office visits, telemedicine or consultations that have been completed and the patient has been seen by a provider are
non-refundable.
Initial
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Email visits are $50.00 and are intended for brief questions regarding the patient's current treatment plan. Email visits are subject to no more than 2 exchanges each by patient and provider, and for established patients only. More than 2 exchanges will require an office or telemedicine visit. Email visits are only available to established patients.
Initial
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Provider appointments which are 30 min will consist of 20 min in clinical time and 10 min of charting time. Appointments that are 60 min in length will be 50 min of clinical time and 10 min of charting time.
Initial
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Office visits can be scheduled as in-office or telemedicine, based on patient request.
Initial
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After each appointment, the patient will receive an individualized treatment plan for reference.
Initial
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Patients must be available 30 mins prior to their telemedicine or in-person appointment for the Medical Assistant to review the patient's medical history (triage). The Medical Assistant will contact the patient with 2 telephone calls and 1 email to confirm the appointment and to ensure the video conference link is properly working. If the patient is unavailable, they will forfeit their deposit and will need to reschedule their appointment.
Initial
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Prescription refills are issued to both compounding and retail pharmacies. Patients must allow 48 hrs. (2 business days) for retail refills and 72 hrs. (3 business days) for compounding refills to process within our office. After this timeframe, patients are required to contact their pharmacy prior to pickup to confirm the refill has been completed.
Initial
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All provider communication is available only during regular business hours via email or phone. Correspondence is intended for brief questions regarding your plan. Any detailed questions will require an office visit.
Initial
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An existing patient is defined as visiting the office within a 2-year (24 mos.) timeframe. Anything outside of 2-years (24 mos.) will be considered as a new patient and requires an initial office visit with any provider at the listed rate.
Initial
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Deposit of $75 must be made at the time of scheduling. Reimbursement for scheduled office visits is available if canceled before 72hrs. (3 business days) of appointment time. If cancellations or rescheduling occur after 72hrs. (3 business days) the patient will forfeit their deposit. Balance is due at time of appointment.
Initial
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Please refer to our BHRT information and pricing at FWIMED.com/providerfees. BHRT pellet therapy pricing may vary based on dosage. A Superbill will be provided per patient request for out-of-network insurance billing for office visits and BHRT pellet therapy.
Initial
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Bioidentical hormone pellets will require bloodwork for the first two pellet insertions. Once symptoms have stabilized bloodwork will only be required annually.
Initial
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Interest accrues at the rate of 1% per month for any amounts remaining unpaid for more than ninety (90) days following the date of the service. Additional charges for returned checks ($25.00 per check) will be invoiced to the patient and are due prior to the next appointment.
Initial
Fort Wayne IV Lounge and Ft. Wayne Integrative Medicine maintain a social media presence which can include photographs of patients, patient's families, and therapy sessions. Inclusion for the social media presence is strictly voluntary and is not endorsed or compensated. To enable Fort Wayne IV Lounge and Ft. Wayne Integrative Medicine to include a photo for our social media or print materials, we require a signature. I waive any right to inspect and approve the finished product or copy. Fort Wayne IV Lounge and Ft. Wayne Integrative Medicine offers appointment and lab reminders by directly texting patients. Patient information will not be shared or published.
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