I understand that Designed Clinical Nutrition is not a method for diagnosing or treatment of any disease including conditions of cancer, AIDS, infections, or other medical conditions and that these conditions are not being tested for, or treated. I understand the DCN is a means by which the neurological reflexes can be used to determine possible nutritional imbalances, bringing the body to a more optimum state of health.
If yes, what please indicate which form:
How many times per week do you consume the following types of food?
Please complete the following chart as it relates to your bowel movements:
Because stress has a direct effect on your overall health and wellbeing that often leads to illness, immune system dysfunction, and emotional disorders, it is important that your health care provider is aware of any stressful influences that may be impacting your health. Informing your doctor allows him/her to offer you supportive treatment options and optimize the outcome of your health care.
How are the following aspects of your life going for you?
Please describe the severity of your pain. Example: Neck 6 (0= no pain, 10= severe pain)
Below are a list of diseases which may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your overall course of care.
PATIENT CONSENT FOR USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATIONTO CARRY OUT TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS
I, hereby state that by signing ‘this Consent, I acknowledge and agree as follows:
I have read and understand the foregoing notice, and all of my questions have beenanswered to my full satisfaction in a way that I can understand.
*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 métabolize and utilize the nutrients you consume, If you:have a specific diseaseand desire treatment for that specific disease entity, you should place yourself under the care of a specialist forsuch 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
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.
I AGREE TO PAY FOR ALL SERVICES RENDERED AT THE TIME 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 48HR 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 APPOINTMENT OR CANCELLATION OF ANY APPTS. CALL THE OFFICE AND LEAVE A MESSAGE
ALL CALLS REQUIRING MORE THAN 5MIN OF ON-LINE TIME WILL GENERATE A CHARGE, REFLECTING THE TIME SPENT ON THE PHONE
NOTE: ALL ACCOUNTS NOT PAID WILL AUTOMATICALLY BE PROCESSED ON YOUR CREDIT CARD.