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Health Goals: _____________________________________________________________________________________________________
Are you interested in any specific therapies? Circle or write in any that you are interested in below:
Nutritional Counseling Hydrotherapy Homeopathy Radio Frequency Sessions Alternative Laboratory Testing
Physical Medicine Mercury/Toxic Metals Detox Acupuncture Whatever the doctor thinks is best
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
***In your own words, describe your health issue(s). Please include a general timeline with approximate age and/or date when you first started to notice a health issue. Describe the changes in your health issue as it progressed from your initial symptom(s) to the current day (if this applies). Additionally, include what was happening in your life leading up to your health issue(s), and your mindset during that time. You can write this statement below. Attach an additional page if needed. Please write as neat/legible as possible. Thank you.
163 Main Street, Westport, CT 06880(203) 864-5762www.TheCenterForNaturalHealth.comDr. Salvatore Fiorentino
CONSENT TO TREATMENT AND ACKNOWLEDGEMENT I, __________________________________________________, as a patient, have the right to be informed about my condition and recommended care. This disclosure’s purpose is to help me become better informed so that I may make the decision to give, or withhold, my consent 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 preventive 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 The Center for Natural Health, LLC and Dr. Fiorentino regarding 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 and Dr. Salvatore Fiorentino, ND to perform the following specific procedures as necessary to facilitate my diagnosis, treatment, and/or sessions. Procedures include, but are not limited to, the following: (1) Intake of present illness and medical history (2) Common diagnostic procedures: may include, but not limited to, laboratory evaluation of blood, urine, stool, hair, saliva, and physical exam. (3) Minor office procedures: e.g., ear cleaning, nasosympatico. (4) Therapeutic use of Nutrition and Dietary advice: therapeutic nutrition/use of foods, diet plans, and nutritional supplementation. (5) Botanical Medicine: therapeutic substances, including plant, mineral and animal materials given in the form of teas, pills/tablets, capsules, powders, and tinctures which may contain alcohol, topical creams, pastes, plasters, washes, suppositories, or other forms. (6) Homeopathic medicine/remedies: often highly diluted quantities of naturally occurring substances/elements to gently stimulate the body’s healing processes, given orally or topically. (7) Naturopathic Hydrotherapy: the therapeutic use of electromagnetic therapies, of hot and cold water applications, thermal or cryo-applications to stimulate healing. (8) Counseling and stress management and the ordering of lab procedures: 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. (9) Naturopathic soft tissue Manipulation: including, but not limited to, massage, myofascial release, and cranio-sacral therapy. (10) Naturopathic Physical Manipulation: specific manipulation of muscles and joints or soft tissue. (11) Frequencies Generator Sessions: sessions consist of audio frequencies passing through the body via metal cylinders and metal foot plates or through non-contact method (through the air).
Please initial each page: _____________ Date: ______________
163 Main Street, Westport, CT 06880(203) 864-5762www.TheCenterForNaturalHealth.comDr. Salvatore Fiorentino
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 from soft tissue manipulation; and an aggravation of preexisting symptoms, any reactions to radio frequencies sessions, 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, cancer, pace makers, electronic pumps, and any internal metal devices -staples – screws – clips - etc. for your safety, it is important to alert Dr. Fiorentino of these conditions immediately. I have been informed of 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 for this 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 ______________________________________________ Date ______________________________
Signature of Patient/Guardian _____________________________________ Relationship to Patient: ______________
Please initial each page: _____________ Date: ______________
163 Main Street, Westport, CT 06880(203) 864-5762www.TheCenterForNaturalHealth.comDr. Salvatore Fiorentino
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 these laws are complicated, but we must provide you with the following information:
The following circumstances may require us to use or disclose your health information:
1. To public health authorities and health oversight agencies which 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 at 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.
Please initial each page: _____________ Date: ______________
163 Main Street, Westport, CT 06880(203) 864-5762www.TheCenterForNaturalHealth.comDr. Salvatore Fiorentino
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 which 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
I have received the Notice of Privacy Practices and I have been provided an opportunity to view it. Name: __________________________________________________________ Birthdate: _______________________________________ Signature: _____________________________________________________ Date: ______________________________________________
Please initial each page: _____________ Date: ______________