Medical Questionnaire

---

---

In case of emergency...

Medical Questionnaire

Medical Questionnaire

Medical Questionnaire

Medical Questionnaire

Medical Questionnaire

Medical Questionnaire

Medical Questionnaire

Medical Questionnaire

 

 

Medical Services Disclosure and Consent

I voluntarily request that the practitioners at C3CareCenter treat my condition (or the condition of the person for whom I am responsible) with the use of conventional, Integrative/Functional Medicine and coaching.

I understand that Integrative and Functional may consist of natural prescribed medication, homeopathic remedies, herbal and nutritional therapies, off label use of pharmaceuticals and supplements. I realize that there may be risks and hazards in treating this present health condition, with or without conventional medicine and there may also be risks and hazards related to using integrative and holistic medicine, including worsening of present symptoms, development of new symptoms and undesirable interactions between various treatments, both conventional and integrative.

I understand that no warranty or guarantee has been made regarding any treatment results.

I understand that I, as the patient or the personal legally responsible for the patient am responsible for my health and that I will not hold the practitioners’ legally responsible for my healthcare and treatment.

SIGNATURE OF PATIENT OR LEGALLY RESPONSIBLE PERSON REQUIRED BELOW

By typing/signing my name below, I certify that I have read the contents of this form (or have had it read to me) and that I understand its contents.

Email Consent

Email offers us an easy and convenient way to communicate between office visits. For us to serve you best, we ask that you follow the below guidelines for email communication.

Conditions for email communication:

• Emails are great for asking general questions that do not require detailed discussion and for clarification of previous recommendations.

• Emails are not meant to replace in-person or phone appointments, nor are they meant to discuss new wellness concerns or receive new wellness consultations.

• Although we do check email regularly, we cannot guarantee that we will be able to answer your email right away nor can we guarantee that we will receive it. Call the office if the matter is urgent or if you do not hear back from me within a reasonable amount of time.

• Confidentiality is not guaranteed with emails! It is like sending a postcard in the mail.

• Email is never appropriate for emergency situations. Please call your local emergency department.

• Emails may be added to your patient chart.

 Consent Notice of Privacy Practice (HIPAA)

Your Information. Your Rights. Our Responsibilities. 

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

 

Your Rights

• Get an electronic or paper copy of your medical record
• As us to correct your medical record
• Request confidential communications
• Ask us to liimt what we use or share
• Get a list of those with whom we've shared information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you feel your rights are violated

Your Choices

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hosital directory
• Contact you for fundraising efforts

In these cases we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your information
• Most sharing of physiiotherrapy notes

Our Uses and Disclosures

We typically use or share your health information in the follwoing ways:

• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers' compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions

Our Responsibilities

We are required by law to maintain privacy and security of your protected health information.

We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

We must follow the duties and privacy described in this notice and give you a copy of it. 

We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. 

 

Change to Terms of This Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.