Patient Information

Patient Information

Demographics & Medical History
Date

MonthDayYear
Today's Date
Patient Demographics
Name

First NameLast Name
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
For our SMS privacy policy, please visit https://rootcauses.com/sms-privacy-policy/

Patients may rescind text and email permissions at any time but updating their contact preferences within the electronic health record, or by emailing sa.admin@rootcauses.com.
Authorization to Receive Texts and Emails
Gender at Birth
Marital Status
Occupation
How did you hear about Root Causes?
Emergency Contacts
Emergency Contact Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Patient
Parents Names & Contact Information
If patient is a minor child, please include above the names and phone numbers of all parents authorized to request medical treatment on the child's behalf and access to their health record. If you are not a minor child, please type "N/A."
Pharmacy Preference
Pharmacy Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Pharmacy Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Health Insurance

(For use with some laboratory testing and radiology orders only. Please remember to upload a copy of both sides of all insurance cards in the patient portal, Cerbo.)
Do you have health insurance?
Insurance Carrier Name
Member ID
Group Number
Billing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Billing Phone:
This is located on the back of your member card.Format: (000) 000-0000.
I acknowledge that Root Causes Medicine is NOT a participating provider with any commercial insurance, entitlement program or cost-sharing organization. Receipts will NOT be provided that contain procedure or diagnosis codes, and no itemization of services is available for insurance reimbursement purposes. While my insurance may be billed for lab work, I am responsible for any portion that is not covered.
Insurance Billing Acknowledgement
I understand that I will be charged and I agree to pay a fee of $150 for appointments scheduled with physicians, naturopathic doctors, psychologists, nurse practitioners and nutritionists that are no-showed or cancelled with less than 24 hours notice.

I understand that I will be charged and I agree to pay a fee of no less than $100 plus the cost of any medications prepared for me that must be discarded for appointments scheduled in the infusion center that are no-showed or cancelled same day.

I understand that a grace period of 15 minutes will be given should I arrive late for my appointment, and that such time will be deducted from my scheduled consultation. Should I arrive later than 15 minutes, I may be asked to reschedule and may still be charged the no-show/cancellation fee.
Appointment Cancellation/No-Show/Late Arrival Policy Acknowledgement

Patient Narrative
Please provide a brief personal medical history in your own words, starting with the last time you felt vibrantly healthy.

Rows	Never	Within 1 Year	2-5 Years	Over 6 Years	Comments
Colon Hydrotherapy
Colonoscopy
Electrocardiogram (ECG/EKG)
Endoscopy
Physical
Sigmoidoscopy

Rows	Brand	Medication Name	Dosage Amount (Strength in Mg)	Dosage Frequency	Ordering Doctor
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Patient Information

Patient Demographics

Emergency Contacts

Pharmacy Preference

Health Insurance

Medical History