New Patient Questionnaire
Legal Name of Patient
*
First Name
Last Name
Name of Patient Representative
*
Relationship to Patient
*
Birth Sex
*
Date of Birth
*
-
Month
-
Day
Year
Date
How old are you?
*
Email Address - This is where we will send our reply to your submission.
*
example@gmail.com
Phone Number
*
Please enter a valid 10-digit phone number
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What conditions are you looking to have assessed and treated?
*
How did you hear about our practice?
*
Google Search, Friend/Family member, Referral from another healthcare provider, etc.
Have you ever worked with a Naturopathic Doctor before?
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No
Yes
Naturopathic Medicine utilizes functional testing and nutraceutical supplements that are not covered by insurance. Do you have the financial resources to cover out of pocket medical costs? (Please refer to our Integrative Concierge Care page for more info on subscription prices.)
*
Naturopathic Medicine is a collaboration between the doctor and the patient in which the patient does as much, if not more work than the doctor to heal. Are you willing to make changes to your lifestyle that will encourage the healing process?
*
Naturopathic Doctors in the State of Maine serve as specialists only and are not primary care doctors. As such, we ask that all patients have a PCP or are actively seeking one. Do you have a primary care physician? Do you have a good relationship with your primary care doctor?
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What medical diagnosis have you received?
*
NENH communicates with its patients through an electronic medical records system to maximize efficiency of our staff. Are you able to utilize email?
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Yes
No
Have you reviewed the Integrative Concierge Care model and policies located on our website?
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Yes
No
Are you prepared to commit to a 12-month membership subscription to Integrative Concierge Care?
*
Yes
No
Please see Integrative Concierge Care page for subscription details and feel free to clarify any questions below.
*
We will reply to the email address you provide on this form.
*Due to the number of new patient inquiries we receive, please allow up to 3-4 weeks for a response.*
Submit
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