Synergyhealthassociates.com - Metabolic Assessment Form

Please note the brand of product you use

i.e. Toothpaste: Crest
Shampoo
Toothpaste
Hair Conditioner
Makeup
Lipstick
Make-up Foundation
Deodorant
Perfume
Hairspray
Shaving Cream
Cologne
Facial Creams
Facial Creams
Do you have hair permanents?

YesNo
Do you have hair colorings?

YesNo
Do you use Latex products?
Do not have a water purification system?
Live near a landfill?
Heavy Metals, Mold, and General/Miscellaneous Toxins
Use a humidifier? Last time cleaned
Had mercury fillings removed?. When
Exposed to radiation? When
Live in an apartment? How old?
For Women: Have breast implants?

YesNo
If yes
Has any type of metal been used in implants or joints replacements in your body?When & Where
Notice symptoms at work more than at home or vice versa?
Have you ever worked in a mall? When
Lived or traveled outside US. Where?
Bought new furniture? Type of Material
Bedroom contents
Mattress Type
Hobbies and other activates

	Problem
Mother
Father
Brother
Sister
Spouse
Child

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
Requesting records of Dr.
Address

Street Address

Street Address Line 2

City/SuburbState / Province

Postal / Zip CodeCountry
Telephone number
Please enter a valid phone number.
Fax number
THE PURPOSE FOR THIS RELEASE
You are hereby authorized to furnish and release to Type a label all information from my medical, psychological, and other health records, with no limitation placed on history of illness or diagnostic or therapeutic information, including the furnishing of photocopies of all written documents pertinent thereto.

In addition to the above general authorization to release my protected health information, I further authorize release of the following information if it is contained in those records
Alcohol or Drug Abuse

YesNo
Genetic Testing

YesNo
Communicable disease related information, including AIDS or ARC diagnosis and/or HIT or HTLA-III test results or treatment

YesNo
Please note: With respect to drug and alcohol abuse treatment information, or records regarding communicable disease information, the information is from confidential records which are protected by State and Federal laws that prohibit disclosure with the specific written consent of the person to who they pertain, or as otherwise permitted by law. A general authorization for the release of the protected health information is not sufficient for this purpose.

This authorization can be revoked in writing at any time except to the extent that disclosure made in good faith has already occurred in reliance on this authorization.
I hereby release (Name of physician, clinic name, or health organization) employees of agents managing members, and the attending physician(s) from legal responsibility or liability for the release of the above information to the extent authorized. A copy of this authorization shall be as valid as the original.

I understand that there may be a fee for this service depending on the number of pages photocopied. However; no such fee will be charged if these records are requested for continuing medical care.
Patient’s Name
D.O.B

MonthDayYear
Date
Signature

Clear
Date

MonthDayYear
Date
Records Requested by: Doctor's Name:
Signature (LORETTA T. FRIEDMAN, RN,MS,DC,CCN,CNS,DACBN,DCBCN)

Clear

SYNERGY HEALTH ASSOCIATES
80 FIFTH AVENUE, SUITE # l204
NEW YORK, NY 10011

PATIENT CONSENT FOR USE AND/OR
DISCLOSURE OF PROTECTED HEALTH INFORMATION
TO CARRY OUT TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS

I, hereby state that by signing this Consent, I acknowledge and agree as follows:

1. The Practice's Privacy Notice has been provided to me prior to my signing this Consent The Privacy Notice includes a complete description of the uses and/or disclosures of my protected health information ("PHI'') necessary for the Practice to provide treatment to me, and also necessary for the Practice to obtain payment for that treatment and to carry out is health care operations. The Practice explained to me that the Privacy Notice will be available to me in the future at my request. The Practice has further explained my right to obtain a copy of the Privacy Notice prior to signing this Consent, and has encouraged me to read the Privacy Notice carefully prior to my signing this Consent.

2. The Practice reserves the right to change its privacy practices that are described in its Privacy Notice, in accordance with applicable law. . ·

3. I understand that, and consent to, the following appointment reminders or communications that will be used by the Practice:
1. A postcard mailed to me at the address provided by me; and
2. Telephoning my home and leaving a message on my answering machine or with the individual answering the phone.
4. The Practice may use and/or disclose my PHI (which includes information about my health or condition . and the treatment provided to me) in order for the Practice to treat me and obtain payment for that treatment, and as necessary for the Practice to conduct its specific health care operations.

5. I understand that I have a right to request that the Practice restrict how my PHI is used and/or disclosed to carry out treatment, payment and/or health care operations. However, the Practice is not required to agree to any restrictions that I have requested. If the Practice agrees to a requested restriction, then the restriction is binding on the practice. .

6. I understand that this Consent is valid for seven years. I further understand that I have the right to revoke this Consent, in writing, at any time for all future transactions, with the understanding that any such revocation shall not apply to the extent that the Practice has already taken action in reliance on this consent.

7. I understand that if I revoke this consent at any time, the Practice has the right to refuse to treat me.

8. I understand that if l do not sign this Consent evidencing my consent to the uses and disclosures described to me above and contained in the Privacy Notice, then the Practice will not treat me.

I have read and understand the foregoing notice, and all of my questions have been answered to my full satisfaction in a way that I can understand.
Name of Individual
Signature of Individual

Clear
Signature of Legal Representative

Clear
Relationship
Date Signed

MonthDayYear
Date
*Attorney-In-Fact, Guardian, Parent if a minor

Agreement Concerning Scope of Care

Dear Patient,
You have to come to us with the desire to improve your general health through nutrition. You may or may not at the same time be under the care of another physician for primary care or for a specific ailment. It's important to understand clearly the·scope and extent of the medical services, which we expect to render in your case. Since a nutritional deficiency may or may not be associated with a specific disease, or may be the cause of that disease, or may occur as,.a result of that disease, our concern with your case will be with your nutritional program and your ability to metabolize and utilize the nutrients you consume. If you have a specific disease and desire treatment for that specific disease entity, you should place yourself under the care of a specialist for such diagnosis and treatment as may be indicated or desired by you.

In our nutritional management of your case we may prescribe vitamins, minerals, enzymes, and other nutritional supplements. The purpose of these natural prescriptions is limited to:

➢ Improvement of your overall nutritional status
➢ Improvement of your metabolism
➢ Increasing your sense of well-being
➢ Normalizing your appetite
➢ Reducing your pain and discomfort

It is important to understand that you may not receive any of these benefits. Results do not occur predictably in every patient, and in some cases they do not occur at all.

The American Medical Association, the Food and Drug Association, the American Cancer Society, the Arthritis Foundation, the American Heart Association or similar agencies or organizations, do not necessarily share our viewpoint concerning nutrition and the diagnostic evaluation of disease. Though significant evidence exists to consider such diagnostics and natural treatments safe and effective, the above agencies of organizations may consider them unproved, investigational or experimental. Signing below you acknowledge that, with full knowledge of these disagreements, you desire to undertake diagnostic evaluation and have prescribed in your case such nutritional supplements and natural treatments which, in our opinion, appear to be indicated for your condition.

Sincerely,

I have read and understand the above. Under the conditions indicated, I hereby place myself under your care for such diagnosis, care, treatment, prescriptions, and therapies as may appear to be indicated in your medical judgment.
Patient
Date

MonthDayYear
Date
Witness
Notary
Synergy Health Associates
Dr. Loretta T. Friedman
80 Fifth Ave. Ste 1204
New York, NY 10011

I AGREE TO PAY FOR ALL SERVICES RENDERED AT THE TlME OF SERVICE.

PLEASE BE ADVISED THAT THIS OFFICE DOES NOT ACCEPT ASSIGNMENT AS PAYMENT FROM ANY INSURANCE COMPANY INCLUDING MEDICARE / MEDICAID WORKER'S COMP. & PERSONAL INJURIES CLAIMS.

PLEASE BE ADVISED THAT THERE IS A 48 HR CANCELLATION NOTIFICATION POLICY FOR ALL MISSED APPOINTMENTS.· (Failure to give us 48hr notice will result in a fee based on the length of time of the appointment.).

ALL TELEPHONE CALLS WILL BE ANSWERED AS SOON AS THE DOCTOR IS FREE TO CALL.
ALL EMERGENCY CALLS WILL INTERRUPT THE DOCTOR FOR AN IMMEDIATE RESPONSE.

DO NOT CALL TEXT OR EMAIL THE DOCTOR FOR ANY APPOINTMENTS OR CANCELLATION OF ANY APPTS CALL THE OFFICE AND LEAVE A MESSAGE***

ALL CALLS REQUIRING MORE THAN 5 MIN OF ON-LINE TIME WILL GENERATE A CHARGE, REFLECTING THE TIME SPENT ON THE PHONE.

NOTE: THESE ARE FEES FOR SERVICE AS WELL
THIS IS NOT PAYABLE BY INSURANCE

NOTE: ALL ACCOUNTS NOT PAID VIILL AUTOMATICALLY BE PROCESSED ON YOUR CREDIT CARD.
PATIENT SIGNATURE

Clear
DATE

MonthDayYear
Date

Loretta T. Friedman, RN,MS,DC,CCN,CNS,DACBN,DCBCN

New Patient Form

OFFICE POLICY

48-HOUR CANCELLATION NOTICE FOR ALL APPOINTMENTS IS REQUIRED.

REGARDING PAYMENT: AS THE PATIENT YOU ARE RESPONSIBLE TO PAY FOR ALL SERVICES RENDERED AT THE TIME OF TREATMENT. DR. FRIEDMAN WILL PROVIDE YOU WITH A BILL TO SUBMIT TO YOUR INSURANCE COMPANY FOR REIMBURSEMENT.
THIS IS FOR:
(SECURE 120 MIN appt w/credit card)
NAME
ADDRESS

Street Address

Street Address Line 2

City/SuburbState

Zip/Post CodeCountry
RESIDENCE
PHONE
Please enter a valid phone number.
EM
BUSINESS PHONE
Please enter a valid phone number.
CELL PHONE
Please enter a valid phone number.
REFERRED BY
CREDIT CARD TO HOLD LYMPH APPOINTMENT
NUMBER
CHIEF COMPLAINT
**ALL NEW PATIENTS WE HAVE 48 HOUR CANCELLATION POLICY
**ALL NEW PATIENTS DO NOT CONTACT THE DOCTOR BY TEXT, EMAIL
OR CELL PHONE TO MAKE APPOINTMENTS OR CANCEL APPTS.
** PLEASE CALL THE OFFICE ONLY***
Should be Empty:

Metabolic Assessment Form

Part I

Part II

Category I

Category II

Category III

Category IV

Category V

Category VI

Category VII

Category VIII

Category IX

Category x

Category XI

Category XII

Category XIII

Category XIV

Category XV (Males Only)

Category XVI (Menstruating Females Only)

Category XVII (Menopausal Females Only)

Environmental Influences Questionnaire

Toxin Exposure

Please note the brand of product you use

Confidential Patient Health Record

CURRENT HEALTH CONDITION

PAST HEALTH HISTORY

CHECK ANY OF THE FOLLOWING YOU HAVE HAD THE PAST 6 MONTHS

FEMALES ONLY

FAMILY HISTORY

READINESS ASSESSMENT

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

THE PURPOSE FOR THIS RELEASE

RESIDENCE