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Patient Information: (Please Print)
Name: ________________________________ Date of Birth: ____________ Age: ____ Gender: M F
Address (Street): _______________________________________________________________________
City: ________________________________ State: ______________ Zip Code: ___________________
Phone (h): ________________________ (c): ______________________ (w): _______________________
Preferred Method of Contact: ____________________________________________________________
SS#: _____________________________ Occupation: _________________________________________
Name of Employer: ______________________ Employer’s Address: ___________________________
Email Address: _________________________________________________________________________
Marital/Relationship Status: _____________________________________________________________
If Minor, Name of Parent/Guardian: ______________________________________________________
Children/Dependents: ___________________________________________________________________
Emergency Contact (Name): _____________________________________________________________
Relationship to you: _____________________________________________________________________
Phone (h): _________________________ (c): ______________________ (w): _______________________
Primary Care Physician (Name & Phone): _________________________________________________
How did you hear about The Center for Natural Health, LLC? ______________________________
________________________________________________________________________________________
Name of Health Insurance Co.: ___________________________________________________________
Does your Health Insurance Cover Out-of-Network Doctors? Example, PPO or POS: _________
I authorize The Center for Natural Health, LLC to call and/or leave a message on the following:
Home Phone: ____________________________________ Leave a message on this line: Yes No
Cell Phone: ______________________________________ Leave a message on this line: Yes No
Office Phone: ____________________________________ Leave a message on this line: Yes No
Email: _______________________________________________________Leave a message: Yes No
Signature: ____________________________ Print:___________________________ Date: __________
Dr. Salvatore Fiorentino, ND, MS
163 Main Street, Westport, CT 06880 www.DrSFiorentino.com
Phone: (203) 864-5762
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Informed Consent to Treatment and Acknowledgement
I, __________________________________________________, as a patient, have the right to be informed about my condition and recommended care. This disclosure is to help me become better informed so that I may make the decision to give, or withhold, my consent as to whether or not to undergo care having had the opportunity to discuss the potential benefits, risks, and hazards involved. A naturopathic physician/doctor (N.D.) is trained as a physician specializing in natural and preventative medicine and is recognized as such by medical licensing laws in the state of Connecticut. In order for Connecticut to issue a naturopathic medical license, the physician must have graduated from a four year, graduate level naturopathic medical college and successfully completed both the National and the Connecticut Naturopathic Physicians Licensing Exams. Dr. Fiorentino is a licensed naturopathic physician in the state of Connecticut. I understand that I have the right to ask questions and discuss to my satisfaction with Dr. Fiorentino the following: (1) my suspected diagnosis or condition, (2) the nature, purpose and potential benefits of the proposed care, (3) the inherent risks, complications, potential hazards, or side effects of treatment or procedure, (4) the probability or likelihood of success, (5) the reasonable available alternatives to the proposed treatment or procedure, and (6) the possible consequence if treatment or advice is not followed and/or nothing is done. I,__________________________________________________, hereby authorize the doctor(s) of The Center for Natural Health, LLC (Dr. Salvatore Fiorentino, ND) to perform the following specific procedures as necessary to facilitate my diagnosis and treatment(s) include, but is not limited to the following: (1) Common diagnostic procedures: including but not limited to general physical exams, PAP smears, blood and urine lab work. (2) intake of present illness and medical history. (3) common diagnostic procedures: (laboratory evaluation of blood, urine, stool, hair, saliva, and physical exam) (4) Minor office procedures: e.g., ear cleaning, nasosympatico. (5) Therapeutic use of nutrition and dietary advice: (therapeutic nutrition/use of foods, diet plans, and nutritional supplementation). (6) Botanical medicine: (therapeutic substances including plant, mineral and animal materials given in the form of teas, pills/tablets, capsules, powders, tinctures which may contain alcohol, topical creams, pastes, plasters, washes, suppositories, or other forms). (7) Homeopathic medicine/remedies: (often highly diluted quantities of naturally occurring substances/elements to gently stimulate the body’s healing processes, given orally or topically). (8) Naturopathic hydrotherapy (the therapeutic use electromagnetic therapies, of hot and cold water applications, thermal or cryo-applications to stimulate healing). (9) Counseling and stress management and the ordering of lab procedure: (including but not limited to imagery (including X-Rays, Ultrasound, Thermal Imaging, and other imaging), visualization and breathing exercises for improved lifestyle strategies and wellness, ). (10) Natuopathic soft tissue manipulation (including but not limited to massage, myofascial release, and cranio-sacral therapy, and naturopathic physical manipulation (specific manipulation of muscles and joints or soft tissue). I understand, recognize and am informed that in the practice of Naturopathic Medicine there are benefits and risks with evaluation and treatment including, but not limited to the following: Potential risks: sensitivities and/or allergic reactions to prescribed botanicals/herbs and/or nutritional supplements; sensitivities, incompatibilities, and/or reactions to prescribed botanicals/herbs and/or nutritional supplements when used in conjunction with other undisclosed prescriptions and/or over the counter medications; pain, discomfort, minor bruising, discoloration, and/or emotional upset
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from soft tissue manipulation; and an aggravation of preexisting symptoms, as well as healing reaction as defined below, inconvenience of lifestyle changes, or procedures. Healing Reaction: Natural healing may occasionally generate a “healing reaction.” If this is anticipated, we will offer you specific information about this phenomenon. Generally, this will occur as a flu-like state with fever or a worsening of symptoms for a few days. It can also, however be different than this and may require expert attention and guidance. Potential benefits: restoration of the body’s maximal functioning capacity, relief of pain and symptoms of disease, assistance in injury and disease recovery, and prevention of disease or its progression. Notice to pregnant women: all female patients must alert Dr. Fiorentino if they know or suspect that they are pregnant, since some of the therapies could present a risk to the pregnancy. Notice to individuals with bleeding disorders, pace makers, and cancer: for your safety it is important to alert Dr. Fiorentino of these conditions immediately. I have been informed and understand the following: (1) the treatment or therapies rendered or recommended by Dr. Fiorentino may be different than those usually offered by a medical doctor or other licensed healthcare practitioner; (2) Dr. Fiorentino is not a medical or osteopathic physician (M.D. or D.O.); since he is not licensed to practice those forms of medicine, I understand that Dr. Fiorentino may refer me to a medical doctor for diagnostic procedures, as well as for conditions requiring conventional medication; (3) Dr. Fiorentino’s care does not replace the care of my primary care physician, and his recommendations will be complementary to my conventional care; (4) Dr. Fiorentino will not suggest or recommend that I refrain from seeking or following the advice of another licensed healthcare professional; and (5) Dr. Fiorentino is not a psychologist or psychiatrist; his counseling services are intended for improving lifestyle strategies and promoting wellness. I hereby request and voluntarily consent to examination and treatment with Naturopathic Medicine by Dr. Salvatore Fiorentino. I understand that unanticipated risks and complications can occur in treatment, and I wish to rely on Dr. Fiorentino to exercise all judgment during the course of treatment, based on the known facts. I understand that it is my responsibility to request that Dr. Fiorentino explain therapies and procedures to my satisfaction. I further acknowledge that no guarantees have been made to me concerning the results intended from the treatment by the doctor(s) or staff of The Center for Natural Health. By signing below I acknowledge that I have been given ample opportunity to read this form or that it has been read to me. I understand the above and give my oral and written consent to the evaluation and treatment. I intend this as a consent form to cover the entire course of treatments for my present condition and any future condition for which I seek treatment.
Print Patient Name ____________________________________________________________________________________________
Signature of Patient __________________________________________________ Date ________________________________
Print Parent/Guardian Name_________________________________________________________________________________
Signature Parent/Guardian __________________________________________ Date ________________________________
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NOTICE OF PRIVACY PRACTICE
To our patients: This notice describes how health information about you, as a patient of this practice, may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Our commitment to your privacy
Our practice is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information.
We realize that these laws are complicated, but we must provide you with the following information:
Use and disclosure of your health information in certain special circumstances
The following circumstances may require us to use or disclose your health information:
1. To public health authorities and health oversight agencies that are authorized by law to collect information.
2. Lawsuits and similar proceedings in response to a court administrative order.
3. If required to do so by a law enforcement official.
4. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to prevent the threat.
5. If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.
6. To federal officials for intelligence and national security activities authorized by law.
7. To correctional institutions or law enforcement officials, if you are an inmate or under the custody of a law enforcement official.
8. For Workers Compensation and similar programs.
Your rights regarding your health information:
1. You can request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. We will accommodate reasonable requests.
2. You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations. Additionally, you have a right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.
3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to: The Center For Natural Health, LLC, P.O. Box 413, Greens Farms, CT 06838.
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4. Note: We must respond to this request within 30 days.
5. You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to The Center for Natural Health, LLC, P.O. Box 413, Greens Farms, CT 06838. You must provide us with a reason that supports your request for amendment.
Note: We must respond within 60 days. The Privacy Officer or the patient’s doctor will usually do this. If the doctor believes the information is complete and accurate, the doctor can refuse to make any changes.
6. You are entitled to receive a copy of this Notice of Privacy Practices. You may ask us to give you a copy of this Notice at any time. To obtain a copy of this notice, contact the front desk receptionist/office manager.
7. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Dr. Fiorentino at The Center for Natural Health, LLC, P.O. Box 413, Greens Farms, CT 06838. Complaints must be submitted in writing. You will not be penalized for filing a complaint.
8. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.
PRIVACY PRACTICES ACKNOWLEDGEMENT
ACKNOWLEDGEMENT FORM
I have received the Notice of Privacy Practices and I have been provided an opportunity to view it. Name: ________________________________________________________ Birthdate: _________________________________ Signature: _____________________________________________________ Date: _______________________________________
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PERSONAL MEDICAL HISTORY
Name: _________________________________________________________ Date: _______________________________________
List your chief (main) complaint: _______________________________________________________________________
______________________________________________________________________________________________________________
To help us evaluate you better, please place a CHECK MARK next to all the symptoms that you currently now are
experiencing, and/or those that have occurred in the past. If only part of the symptoms apply, CIRCLE that particular
symptom(s).
NOW PAST GENERAL SYMPTOMS
tired, weak, lack of energy
depression, melancholy, moodiness
worry, anxiety, nervousness, irritability
sleeplessness or sleep too much
frequent colds or other illness
headaches
don’t sweat enough
sweat too much
night sweats
dizziness, fainting, convulsions
loss or gain of weight
other:
NOW PAST SKIN & HAIR
acne or pimples
skin rashes
hives
stretch marks
skin ulcers or Sores
dryness roughness or scaling skin,
scalp, elbows, knees, feet,
around nose, ears, eyebrows, etc.
hair loss or thinning
dry, coarse hair or split ends
bruise easily
nails weak, ridged or split easily
brown spots or bronzing on skin
moles, warts or skin tags
sunburn easily
cuts heal slowly or scar badly
flush easily
numb hands or feet or tingling
feet burn, athletes foot
other:
NOW PAST EYES
near or farsightedness
blurred or failing vision
dry, burning or itching eyes
eyes water excessively
eyes sensitive to light
night blindness
bloodshot or puffy eyes
other:
NOW PAST EARS
earaches
noises or ringing in ears
ear discharges
loss of hearing
lots of wax
other:
NOW PAST NOSE & THROAT
hay fever, sinusitis, runny, nose
nosebleeds
cracks in corners of mouth
dry or chapped lips
sore throats or tonsillitis
clear throat often
sore, red or cracked tongue
cold sores or herpes
inability to smell or taste
lots of cavities
bleeding gums
hoarseness
other:
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NOW PAST RESPIRATORY
cough frequently
spitting up mucus or blood
difficulty breathing
shortness of breath on exertion
chest pain
other:
NOW PAST GASTROINTESTINAL
loss of appetite
gagging, difficulty swallowing
nausea or vomiting
bad breath
metallic or bitter taste in mouth
food cravings
can’t eat fats
heartburn
indigestion
heaviness after eating
belching or gas
bloating
stomach or abdomen tender/pain
symptoms relieved by eating
symptoms worse by eating
avoid certain foods
diarrhea or loose stool
constipation
change in bowel movements
light colored or greasy stool
dark stools or blood in stool
feeling of incomplete evacuation
undigested food in stool
foul odor of stool or gas
hemorrhoids
headache, dizziness or irritability when meal skipped
NOW PAST MALE
prostate problems
difficulty or unusual urination
discomfort or pain in genital area
difficulty maintaining an erection
NOW PAST MUSCULO-SKELETAL
muscle pain or stiffness
swollen, painful or stiff joints
bone pains
painful feet, ankles or calves
tremors or twitches
loss of strength
hernia
muscle wasting
other:
NOW PAST MALE
diminished sexual desire
excessive sexual desire
other:
NOW PAST CARDIOVASCULAR
heart beats fast or irregularly
tightness in chest
discomfort at high altitude
dizzy or weak upon standing
swollen feet, ankles or legs
cold hands or feet
hands or feet turn blue
blue fingernails
leg pain when walking
varicose veins
tendency to anemia
high blood pressure
low blood pressure
other:
NOW PAST URINARY
difficulty urinating
urinate frequently at night
bedwetting
incomplete urination
pain when urinating
bladder infections
kidney infections
kidney stones
lower back pain
other:
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NOW PAST FEMALE irregular menstruation
pain prior to or with periods
depressed, tense, or irritable around periods
painful or swollen breasts
lumps in breasts
discharge from breasts
symptoms occur in a monthly pattern
pain, discomfort or itching in genital area
other:
Please proceed to the next page →
NOW PAST FEMALE hot flashes
diminished sexual desire
excessive sexual desire
difficulty having orgasm
inability to conceive
number of pregnancies
number of children
miscarriages or abortions
vaginal discharge
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1. When was your last known period/menses: ________________________________________________________.
2. How many days does it usually last: __________________________________________________________________.
3. What is the total length of your cycle: ________________________________________________________________.
4. Are you currently pregnant? _____________. 5. Number of pregnancies: __________________________.
6. Number of children: _________________. 6. Date of last PAP Smear? ___________________________.
7. Have you ever had an abnormal PAP Smear? _______________________________________________________.
8. Do you use birth control? _______________. 9. If so, what type of birth control? _________________.
10. For how long have you used birth control (if applicable)? ______________________________________.
11. Please give an example of what you eat and drink on a typical day:
Breakfast: _________________________________________________________________________________________________
Lunch: _____________________________________________________________________________________________________
Dinner: ____________________________________________________________________________________________________
Snack: _____________________________________________________________________________________________________
Beverage: __________________________________________________________________________________________________
12. Do you exercise? _________________________ 13. How many days per week? ______________________
14. Do you lift weights? _______________________ 15. Do you run? Jog? Walk? ________________________
16. For how long do you exercise each day? ____________________________________________________________
20. Do you have any known allergies?
Medications (please list all)? ____________________________________________________________________________
___________________________________________________________________________.
Foods: _____________________________________________________________________________________________________
____________________________________________________________________________________________________.
Other: _____________________________________________________________________________________________________
____________________________________________________________________________________________________.
21. Do you use any of the following? Y (Yes) or N (No)
______ Cigarettes/Tobacco ______ Pack per week
______ Coffee or Black Tea ______ Cups per day
______ Alcohol ______ Times per day
______ Marijuana ______ Times per day
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22. Please list if you take any of the following:
Prescription Medication: Dosage: Vitamins and Mineral: Dosage:
________________________________ _______________ _________________________________ ________________
________________________________ _______________ _________________________________ ________________
________________________________ _______________ _________________________________ ________________
________________________________ _______________ _________________________________ ________________
________________________________ _______________ _________________________________ ________________
________________________________ _______________ _________________________________ ________________
________________________________ _______________ _________________________________ ________________
Over –The – Counter Medications: Botanicals / Herbs:
_______________________________________________ __________________________________________________
_______________________________________________ __________________________________________________
_______________________________________________ __________________________________________________
_______________________________________________ __________________________________________________
_______________________________________________ __________________________________________________
_______________________________________________ __________________________________________________
_______________________________________________ __________________________________________________
23. Have you ever had any vaccinations? _______________________________________________________________
24. Have you had the Hepatitis B vaccinations? __________________. If so, When? ____________________
24. Please list if you ever been hospitalized, had any surgeries, serious illnesses, accidents:
List Dates, and What or How it occurred (if applicable):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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FAMILY HISTORY
Has a blood relative ever had any of the following?
Which relative(s)? Details:
Autoimmune Disorder
Ex. MS, Lupus,
Arthritis etc.
Stroke
Epilepsy
Migraines
Thyroid Disease
Cancer
Hepatitis
Tuberculosis
Diabetes
Heart Disease
High Blood Pressure
Gallbladder Disease
Allergies/Hay Fever
Asthma
Kidney Disease
Mental Illness
Suicide
Osteoporosis
Alcoholism/Addition
How much effort are you willing to put into feeling better? (Circle)
NO EFFORT 0 1 2 3 4 5 6 7 8 9 10 WHATEVER IS NEEDED
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POLICIES AND PROCEDURES
New Patients
1st office appointment is usually approximately 1.5 - 2 hours. At this time, we will discuss your health concerns and goals. We will conduct a comprehensive analysis of your current and past medical history. We will analysis any recent laboratory tests that you obtained from other doctors. A review of your current medications and supplements will be conducted.
o Please bring in all prescriptive and over-the-counter medications, and any supplements, herbs, etc. that you are currently taking with you on your first office visit.
A pertinent physical examination will be conducted. We will determine the appropriate laboratory tests needed to address your specific health
concerns. An interim treatment plan will be developed for you until a comprehensive analysis of all lab
results return. Follow up appointments should be booked with us 3 to 4 weeks after your initial appointment.
Return Appointments:
1st time follow up appointments are 45 - 60 minutes. Additional follow up appointments can be 15, 30, 45, or 60 minutes. At this appointment, lab test results will be explained and you will receive an individualized
treatment plan crafted specifically for you. As a courtesy, you will receive a reminder of your appointment via phone call and/or email.
Laboratory Tests:
Our doctors may recommend particular medical laboratory tests because it is a medically useful course of action.
Depending on your insurance, not all laboratory tests may be covered. It is your responsibility to contact your insurance company to help determine coverages. Even when your insurance doesn’t coverage a particular test, it does not mean that you should not have the test completed.
In approximately 2 to 3 weeks from the time that the laboratory receives your specimen(s), your test(s) results will be sent to the attending physician.
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Dr. Salvatore Fiorentino, ND, MS
163 Main Street, Westport, CT 06880 www.DrSFiorentino.com
Fax (203) 441-7009
Phone: (203) 864-5762
Payment Methods:
Payment methods include: o Visa, MasterCard, American Express, Discover Card, PayPal, Check or Cash.
Supplement/Product Orders and Return Policy:
Pre-approval is required on all returns. Refrigerated items, including, but not limited to fish oil and probiotics, cannot be returned. No returns will be accepted for supplements, including vitamins, minerals, botanicals,
homeopathic remedies, natural creams, gels, drops, tinctures etc, after 15 days, with exception to the purchase of our complete Lyme Disease Protocol in advance.
o Advanced purchase of our Lyme Disease Protocol is only returnable within 30 days of initial purchase and only if the bottles were never opened. Once again, refrigerated items cannot be returned.
Once a supplement (item) is opened, it cannot be returned except in special circumstances and with the pre-approval of The Center for Natural Health, LLC.
*Returned Checks:
I understand that my account will be charged $25.00 for any checks returned due to insufficient
funds. I also agree that I am responsible for any collection and/or legal fees. *Cancellation Policy:
I acknowledge that I am required to give a minimum of 24 hours’ notice by phone to cancel my scheduled appointment. Patients who cancel their appointment within less than 24 hour will be billed a $50 missed appointment fee.
I understand that I am wholly and personally responsible for payment on date of service. The Center for Natural Health, LLC is not a participant in Medicare or insurance plans. I realize that I may request the attending physician’s statement of diagnosis and services provided to me, which I may submit to my insurance company for possible reimbursement of the treatment cost, as may be provided by my plan. The Center for Natural Health, LLC does not guarantee that I will receive reimbursement from my insurance carrier. I understand that The Center for Natural Health, LLC, at its option, may charge me interest on any unpaid balances. I have read and agree to the financial terms and cancellation policy above:
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I (print patient or guardian’s name) ____________________________________________________ have read,
understand and agree to The Center for Natural Health, LLC’s Policies and Procedures.
____________________________ ____________________________________________________
Date Print Name (Patient)
____________________________ ____________________________________________________
Date Print Name (Parent/Guardian)
____________________________ ____________________________________________________
Date Patient or Guardian Signature
Thank you for taking the time to complete this form. If you have any additional questions, feel
free to contact our office.
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Dr. Salvatore Fiorentino, ND, MS
163 Main Street, Westport, CT 06880 www.DrSFiorentino.com
Fax: (203) 441-7009
Phone: (203) 864-5762
PATIENT FEES
An example of typical office fees:
Service
Fees
Usually First Office Visit includes: 1 ½ - 2 hours visit with a full case history, pertinent physical examination, urine analysis, weight and body fat percentage assessed, distribution of laboratory test kit(s), and an interim plan of treatment.
$300
Typical Return Office Visit (1hour): Review of test results and follow up evaluation. $180
Constitutional Hydrotherapy Treatments (1 hr) $85
Auricular Acupuncture (lasts 1 week-with acupuncture seeds) $60
Thermal Imaging for breast cancer risk assessment. _________________
Report of Thermal Imaging and therapy plan (30 minutes) $105
Compounded therapeutic treatment remedies and / or supplements. Price varies
*Fees for medical services and supplement prices not listed are available upon request. Laboratory fees
are not included in above fee schedule.
Dr. Salvatore Fiorentino, ND, MS
163 Main Street, Westport, CT 06880 www.DrSFiorentino.com
Fax: (203) 441-7009
Phone: (203) 864-5762
