Intake forms to be completed prior to making an appointment
Family Disease History:
I hereby request and consent to the performance of naturopathic procedures (including examination, diagnostic testing, and the use of natural substances such as vitamins, minerals, botanical medicines, bioidentical hormones, and prescription drugs) on me (or on the patient named below, for whom I am legally responsible) by Dr. Seligman; a licensed Naturopath.
I understand and am informed that, as in the practice of medicine and naturopathic medicine, there are some risks to the exam and treatment including, but not limited to Naturopathic Medicine- drug side effects, nutrient-drug interaction, and herb-drug interactions. I understand and am informed that results from treatments may vary and are not guaranteed. In addition, I understand that my compliance with diet recommendations, supplements, prescribed medications, prescribed exercises, and lifestyle modification will increase the effectiveness of my care and enhance or maintain the results. I understand a referral to another physician or specialist may be necessary due to the nature of my condition and limitations in the scope of practice of Naturopathic Medicine.
I am aware that Naturopathic Physicians are considered primary care providers in the state of Washington. I acknowledge that the scope of practice of a Naturopathic physician has limitations including limited prescription privileges and lack of hospital privileges. Consequently, a referral to a specialist or emergency room may be deemed necessary under certain circumstances and in my best interest.
I do not expect the doctor to be able to anticipate and explain all the risks and complications, and I wish to rely on the doctor to be able to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts known.
I have read, or have had read to me the above consent. I have also had an opportunity to ask questions about its content, and by initialing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
We HIGHLY recommend you careully review all of the information contained in this section.
Additional Information
Supplemental Information
Evergreen Integrative Medicine complies with the Health Insurance Portability & Accountability Act (HIPPA). We protect confidential health care information, known as “Protected Health Information” (PHI). Below is a summary of patient privacy rights under HIPPA and our clinic's legal duties and privacy practices regarding your PHI.
Uses & Disclosures of Your PHI
Patient Privacy Rights
If we change any of the details of this notice, we will notify you of the changes in writing. You may file a complaint with the Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, Washington, DC 20201. You will not be retaliated against for filing a complaint. However, before filing a complaint, or for more information or assistance regarding your health information privacy, please call our office at 425.999-4503. This notice goes into effect as of April 14th, 2003.
Federal law requires that we obtain your written acknowledgment of receipt of the Notice of Privacy Practices. The patient hereby acknowledges that Evergreen Integrative Medicine has provided a copy of its Notice of Privacy Practices that describes how protected health information may be used and disclosed, and how to access this information. I understand that if I have questions or complaints I may contact Evergreen Integrative Medicine. I also understand that I am entitled to receive updates upon request if Evergreen Integrative Medicine amends or changes its Notice of Privacy Practices in a material way.
Your agreement to all policies is required to complete this document and receive an appointment. If you have questions or concerns with any policy or part of this document please contact our office by email at staff@eimed.com.
My signature below is an indication that I have completed this document to the best of my abilities and have reviewed and agree with all policies presented.
Your information will be encrypted.