New Patient Intake Form

- I consent to receive appointment reminders and health-related communications via text and/or email. I understand that while reasonable precautions are taken, these methods may not be fully secure.
- I understand that my insurance benefits are my responsibility to verify. I agree to pay all co-pays, deductibles, and any non-covered or out-of-network services.
- I understand that CanyonCare Integrative Medicine offers both insurance-based and cash-pay services. I agree to pay in full at the time of service for all applicable charges.
- I understand that payment is due at the time of service and that fees for services rendered are non-refundable. I acknowledge that medications, supplements, and injectable treatments are non-refundable once dispensed or administered.
- I understand that a valid credit/debit card or ACH account is required to be kept on file. I authorize CanyonCare Integrative Medicine to securely store my payment information and charge my account for services rendered, membership fees, and applicable cancellation or no-show fees.
- I understand that cancellations or rescheduling within 24 hours of a scheduled appointment, or failure to attend an appointment, may result in a fee of $150 charged to my card on file.
- If I elect to enroll in a membership or recurring service, I authorize ongoing charges in accordance with the agreed-upon plan and understand that I am responsible for these charges unless I cancel according to clinic policy.
- I understand that medical treatments and wellness services may have variable results, and no guarantees are made regarding outcomes.

I understand and accept the Communication & Financial Acknowledgment section (initial below).

I consent to participate in Telehealth visits offered by CanyonCare Integrative Medicine and understand I may withdraw at any time. I understand the potential risks and benefits of receiving care via Telehealth.

We are committed to maintaining the privacy of your medical information. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

- You have the right to: request restrictions on certain uses/disclosures of your information, inspect and copy your medical record, request and amendment to your record and request a list of disclosures.

- For questions or more details, please contact our Privacy Officer at frontdesk@canyoncaremed.com.

- I've reviewed the Notice of Privacy Practices (NPP) above and understand how my information is used. I acknowledge that I have been given the opportunity to ask questions about the NPP for CanyonCare Integrative Medicine, which explains how my medical information may be used and disclosed, and how I can access this information.

- I understand that CanyonCare Integrative Medicine may use or disclose my health information for the purposes of:

  • Treatment: coordinating or managing my care with other healthcare providers

  • Payment: billing and collection activities

  • Healthcare operations: quality assessment, medical reviews, auditing functions, and administrative services.

Patient Rights:

To be treated with respect, dignity, and courtesy without discrimination. -To receive considerate and respectful care at all times.

To privacy and confidentiality of your medical information.

To participate in decisions regarding your healthcare and treatment.

To be informed about your diagnosis, treatment options, and prognosis in understandable language.

To consent to or refuse treatment to the extent permitted by law.

To request access to your medical records and obtain copies as allowed by law.

To voice concerns, complaints, or grievances without fear of reprisal.

To file complaints regarding quality of care or safety concerns directly with the California Department of Public Health or the Centers for Medicare & Medicaid Services (CMS) without fear of reprisal.

To know the identity and qualifications of all staff involved in your care.

To receive information regarding fees, insurance billing, and payment policies.

Patient Responsibilities:

To provide accurate and complete information about your health and medical history.

To follow the treatment plan agreed upon with your provider.

To ask questions when you do not understand instructions or information.

To treat staff and other patients with courtesy and respect.

To keep scheduled appointments or notify the office promptly if you need to reschedule.

To be responsible for payment of services rendered and providing valid insurance information.

 

We encourage open communication and welcome your feedback to help us maintain the highest quality of care.

- I can inspect, amend, and request limits or disclosures of my records.

- I can revoke this consent in writing at any time.

- I consent to care by Dr. Ian Roy and staff at CanyonCare Integrative Medicine.

By signing below, I consent to all sections above. I confirm that the information provided is accurate and complete to the best of my knowledge.