Online Health Consent Form
Name
Middle Name
Prefix
Age
Date of Birth
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Month
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Day
Year
Gender
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Male
Female
Email
Phone Number
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Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Details or Parent/Guardian Info
Contact Person Name
Primary Phone Number
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Area Code
Phone Number
Secondary Phone Number
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Area Code
Phone Number
Medical Data
(If you already answered any of the below questions on the General Client Info form, please enter "see Client Info form" in any field below.)
Blood Type
Please Select
A
B
AB
O
Do you have any known allergies (food, environmental, seasonal, drugs, etc.)? If yes, then please specify below.
Are you currently taking medications? If yes, please list the medications and the reasons why are you taking them.
What is your current medical condition? List any diseases: communicable, heart/lung issues, diabetes, arthritis, etc.
Are you vaccinated? If yes, please list the vaccines you have received.
Acknowledgment, Authorization and Waiver
Please read each statement and check its box:
I understand that Dr. Laura will not diagnose illnesses for me and does not seek to replace my M.D. I understand that Dr. Laura has no prior knowledge of my total medical history that I have not first made her aware of in writing, and therefore, I am responsible for giving her that information in writing so that she might better assist me.
I understand that Dr. Laura has chosen to be a Naturopathic doctor and not a surgeon, medical physician, pharmacist, psychiatrist, or any other licensed medical practitioner. She is a certified "N.D." and not an "M.D.," or "D.O." So, I understand that I am responsible for taking Dr. Laura's lifestyle-change advice back to my medical doctor for consideration.
I understand that Dr. Laura does not seek to replace my pastor and that I am responsible for staying accountable to my local church leaders and informing them of any spiritual advice that Dr. Laura offers me.
I understand that all relationship tips, emotional counsel, occupational pointers, mental guidance or advice of an emotional or mental nature from Dr. Laura is given after hearing my side of situations and that she cannot fully grasp my personal circumstances. Also, (if applicable), any such guidance given does not replace that of my psychologist or psychiatrist and I am responsible for conveying Dr. Laura's suggestions to them myself.
I understand that Dr. Laura will not prescribe medications for me of a conventional nature and that her recommendations for making positive lifestyle change are suggestions and not prescriptions or medical counsel.
I am seeking care from Dr. Laura Harris Smith, a naturopathic doctor, and am aware of the nature of the naturopathic treatments provided. I take responsibility for my own health and release Dr. Laura Harris Smith from any liability, injury or loss of life associated with any guidance she offers.
I acknowledge that I am of sound mind and that all information I provided in this form is true and accurate.
Client Signature
Date Signed
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Month
-
Day
Year
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