Naturalpath Intake Form - ADULT

8/20/2019 Naturalpath Intake Form - ADULT

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Adult Intake Form Contact Information

NameHome Phone

Address Work Phone Address Road

Mobile PhoneCity Province Postal Code

E-mail

List contact information in order of preference:

Primary Contact: Relationship: ________________________

Name Home Phone

Address Work Phone Address Road

Mobile PhoneCity Province Postal Code

E-mail

Medical History

Do you have any allergies (medicines, environmental, etc)?

_____________________________________________________________________________________________

_____________________________________________________________________________________________

How many times have you been treated with antibiotics in the last 5 years? ______

Do you frequently use any of the following? (circle)

Aspirin Laxatives Antacids Diet pil ls Birth control pil ls / implants / injections

Recreational drugs—what and how often ___________________________________________________

Please indicate what immunizations you have had (If you do not remember then leave this section blank)

! DPT (diphtheria, pertussis, tetanus) ! Haemophilus influenza B ! Hepatitis A

! Tetanus booster; when? ______________ ! “Flu” ! Hepatitis B

! MMR (measles, mumps, rubella) ! Polio ! Smallpox

Other __________________________________________________________________________________

Please indicate if any caused adverse reactions

___________________________________________________________________________________

Do you have any food allergies or intolerances? Please list.

_____________________________________________________________________________________________

_____________________________________________________________________________________________



Jason Lee BSc. ND. InnerMedica IncDoctor of Naturopathic Medicine 114 Elmwood Rd905-849-1100 Oakville, ON L6K 2A7

Consent to Naturopathic Treatment and BioEnergetics Treatments

I, as a patient of Jason Lee BSc. RhA, ND, hereby attest to the following:

1) I am here, on this and any subsequent visit, solely on my own behalf and not as an agent for any federal, provincial omunicipal agency on a mission of entrapment or investigation.

2) I fully understand that Registered Holistic Allergists are not medical allergists doctors.

3) I fully understand that Naturopathic Doctors are licensed under the Board of Directors – Drugless Therapy and canprovide medical diagnosis and treatment procedures.

4) The services performed by Jason Lee ND are at all times restricted to consultation on the subject of nutritional matteror the sensitivities to various substances, and does not involve the use of scratch tests, needles or blood tests to verif

the client’s sensitivities or intolerances to foods or environmental substances.

5) The patient should not for any reason, ingest or expose himself/herself to any substance that he/she has previouslybeen diagnosed as allergic or anaphylactic by a qualified physician/allergist unless he/she has first been given consenby a qualified physician/allergist.

6) Treatment Protocol Program compliance is required for guaranteed results.

7) The decision to follow any recommendations made rests solely with the undersigned.

Practitioner Visit: Dr. Jason Lee (ND 1197)

Informed Consent:

Naturopathic Treatment

Naturopathic Doctors obtain informed consent to make sure that you are awareof possible side effects / risks due to treatment and that you are aware of your

rights as a patient of the clinic.

The staff and practitioners at InnerMedica would like to take this opportunity to welcome you to the clinic. The Naturopatportion of this clinic utilizes the principles of the healing power of nature (Vis Medicatrix Naturae) and other supportive therapito assist the body’s own ability to heal and improve the quality of life and health through natural means.

Dr. Jason Lee, ND uses the following modalities in his practice: diet and nutritional counseling, botanical medicine, homeopathacupuncture, bioenergetics treatments, hydrotherapy and lifestyle counselling. As a health provider he will conduct a thoroucase history, conduct a complaint centered physical exam and may use specific blood, urinary or other laboratory tests as parta treatment work-up.

Even the gentlest of therapies have their complications in certain physiological conditions such as pregnancy and lactation,very young children, or those taking multiple medications. Some therapies must be used with caution in certain allerconditions and disease including but not limited to: diabetes, heart/liver/kidney disease and autoimmune disease. It is VERIMPORTANT therefore, that you inform Dr. Jason Lee, ND., immediately if any of the above applies to you as each individumay respond differently to treatment. Dr. Jason Lee., may not be able to anticipate and explain ALL risks and complications.

The slight health risk of some treatments include but are not limited to: aggravation of pre-existing symptoms, allergic reactioto supplements or herbs, pain/fainting/bruising or injury from venipuncture, parenteral therapy, acupuncture or muscle spasmstrains, rib fractures, disk injuries from neuromuscular release therapy.

I also recognize the following:



• Any Treatment or advice provided to me as a patient of the clinic is not mutually exclusive from any treatment that I mnow be receiving or may in the future receive from another licensed health care provider.

• I am at liberty to seek or continue medical care from a medical doctor or other healthcare provider licensed practice in Ontario.

• I am aware that no part of my treatment is covered by OHIP and that I am solely responsible for payment of servicrendered at the end of the appointment.

• I am aware that supplement fees are extra on top of visit costs although patients can purchase supplementhrough the clinic without setting up a visit or can go to other dispensaries for product purchase.

• I fully understand that Naturopathic Doctors are licensed under the Board of Directors – Drugless Therapy and can provmedical diagnosis and treatment procedures.

• I understand that the Naturopathic Doctor reserves the right to determine which cases fall outside their scope of practicewhich event the appropriate referral will be recommended.

• I understand that I may look at my medical record at anytime and can request a copy of it or have a report drawn up paying the appropriate administrative fee.

• I understand that all information provided during my visit is strictly confidential. Information may only be released upon written request or requested by law.

o I acknowledge that I have the opportunity to discuss with Dr. Jason Lee, ND., the nature and purpose of naturopattreatment in general and my treatment in particular.

o I understand that reception or the naturopathic doctor reserves the right to contact you regarding appointmescheduling, re-scheduling, e-mail and clinic address changes or place reminder calls for visits or product.

o I am aware that the clinic is an integrated clinic. In order to provide optimal care, the naturopathic doctor mconfidentially request information from your medical doctor eg. medications, lab results and imaging (X-ray, CT, MRultrasound, bone density, etc.) in order to analyze all components of your case. A “Patient Information Release Forwould be needed to be signed in this case.

o I also confirm that I have the ability to accept or reject this care of my own free will and choice and that I am not agent of any private, local, county, provincial or federal agency to gather information without stating. I accept fresponsibility for any fees incurred during care and treatment.

o I understand that the below price listing is the current price listing for services rendered and that listing is subject

change without prior notice.o I am aware that for the best results, treatment program compliance is required.

o I consent to the naturopathic treatments offered or recommended to me by Dr. Jason Lee, ND. I intend this consentapply to all my present and future naturopathic care.

I am aware that 48 hour notice must be given for all cancelled appointments or a cancellationfee of $70 (for 30 min) and $120 (for 60 min) will be applied

Name:_______________________________________________________________________________

Address:_______________________________________________________________________________

City: ____________________________________________________Province: ______________________

Postal Code: _________________________________ Phone: ___________________________________

Signed:___________________________________________________ Date: __________________



Informed Consent:

BioEnergetics Treatments

Bioenergetics desensitizing is a method that allows the body to adapt to intolerances by removing various stressors the body, which aids the body in gaining homeostasis (balance)

• I am here, on this and any subsequent visit, solely on my own behalf and not as an agent for any federal, provincialmunicipal agency on a mission of investigation.

• I fully understand that Registered Holistic Allergists are NOT medical allergists doctors.

• The BIE services performed by Dr. Jason Lee, ND are at all times restricted to consultation on the subject of nutritionmatters or the sensitivities to various substances, and does not involve the use of scratch tests, needles or blood tests verify the client’s allergies to foods or environmental substances.

• If I am being treated for a serious allergy I should not for any reason, ingest or expose myself to any substance that I hapreviously been diagnosed as allergic or anaphylactic by a qualified physician/allergist unless I has first been given conseby a qualified physician / allergist.

Patient Name:_______________________________________________________________________

Signature of Patient / Guardian:________________________________________________________

Date:______/_______/_______



Fee SchedulePATIENT COPY – Do not return

Patients are responsible for the total charges incurred (visit fees plus any medicine) for each visit. Service are not covered OHIP but may be covered by extended heath plans. It is the patient’s responsibility to assess if they have coverage Naturopathic Medicine and for billing their own insurance company. Most insurance companies will not cover the supplemenprescribed or dispensed. All fees are subject to HST.

Naturopathic Treatment Fees

Visit Type Cost Adult - Initial Consultation – 1 hour visit $185.00 Adult - 1 hour visit $185.00

Adult - 30 minute visit $120.00

Child (under 10) - Initial Consultation – 1 hour visit $170.00Child (under 10) - 1 hour visit $170.00Child (under 10) - 30 min visit $110.00

• all visit fees include sensitivity testing and elimination treatments

• all visit fees do not include lab testing and supplementation

Acupuncture - 30 minute visit (acupuncture only) $70.00

Laboratory Tests / Analysis and Injection Fees

Visit Type CostUrinalysis Test (Screening Test) $5.00Koenigsberg Test (Adrenal Function) $12.00Oxidata Test (Oxidative Damage Test) $24.00Indican Test (Bowel Toxicity Test) $20.00Sulkowich Test (Calcium Test) $12.00Vitamin C Absorption Test $10.00Urine Heavy Metal Screening Test $30.00Blood Typing Test $10.00Skin Sterol Cholesterol Test $45.00Body Index Analysis Test (BIA Test) $12.00Vitamin Injections (per injection) $15.00

Carroll Food Intolerance Test $125.00Live Blood Cell Analysis – 60 minute initial $120.00Live Blood Cell Analysis – 30 minute follow up with Dr Lee $120.00Blood Food Sensitivity Tests Ask naturopathic doctorBlood and Other Medical Tests Ask naturopathic doctor

Note: All prices are subject to change without notice

Documents

Naturalpath Intake Form - ADULT