Forms NEW PATIENT INFORMATION FORM Name * First Name Last Name Date MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * REFERRED BY: Occupation Employer Date of Birth MM DD YYYY Age Height Weight Sex Male Female Overall health (circle one): Excellent / Good / Fair / Poor / Other: Chief complaint (reason you are here): (use separate sheet if more room needed) Previous treatments for this complaint: Other complaints or problems: Are you currently under the care of a physician or other health care professionals? (If yes, please print name and date of last visit): Current medications/drugs being taken: Nutritional supplements you are taking: Do you smoke, drink coffee or alcohol? Cigarettes Coffee Alcohol List any major illnesses (with approx date): List any surgery or operations (with approx date): Past Accidents or injuries: Any scars from injuries, surgeries, piercings, tattoos, childbirth? Any scars from injuries, surgeries, piercings, tattoos, childbirth? Yes No Type of water you drink? Any known allergies? Any recent vaccines? Marital Status: Single Married Divorce Widow Name of Spouse Describe health of spouse: Number of children if any Any family history of serious illnesses (circle those which apply): Cancer / Diabetes / Heart/ Other: Any family members or close associates with recent vaccines? Any household pets or other animals you or family members are in close contact with: What could we do to make you happier? Date MM DD YYYY Payment Agreement Patient Name First Name Last Name Date MM DD YYYY I understand that payment is due at the time of service and that I am financially responsible for all charges. I understand that if I am unable to provide payment at the time of service for whatever reason, a $25 late payment fee will be added on to my account. I understand that a $25 fee will be charged for a missed appointment or cancelled appointments with less than 24 hours advance notice. Exceptions for emergencies or extraordinary circumstances may be made at the discretion of the practitioner. I understand that appointment reminders are a courtesy service and that not receiving an appointment reminder does not exempt me from missed appointment fees. I understand that a $25 fee will be assessed for all returned checks. I understand that all payment types are accepted but that a 3% fee will be assessed for all credit card transactions. I understand that discount treatment packages must be paid in full up front, may not be shared, and are non-transferable and non-refundable. I understand that the fee schedule for appointments (following the initial appointment, which is $250) is as follows and includes time for questions, testing, allergen hold time, acupuncture as needed, and other evaluation or treatment-related activities: By signing below, I, the undersigned, understand and agree to all above policies and statements. Privacy Acknowledgement I have received a copy of the Notice of Privacy Practices. Date MM DD YYYY *If patient is a minor, a parent or guardian must sign. I, certify that Liezl Apante, Certified NAET® Practitioner, does not claim to cure any , illness or disease with NAET® (Nambudripad's Allergy Elimination Technique). I understand that NAET® is not a medical diagnostic procedure and therefore does not diagnose a disease. Rather, NAET® gives the practitioner an indication as to the substance(s) to which the patient may have sensitivity. NAET® uses various, standard medically proven diagnostic measures and modalities (allopathic, chiropractic, kinesiological, and acupressure) to diagnose the patient's condition. The premise behind NAET is to desensitize a patient to the substance(s) using allopathic, chiropractic, acupressure, nutritional and kinesiological principles so that the patient may not experience hypersensitive symptoms when they have future contact with them. I understand that I am (my dependent is) to continue all medication and other treatment modalities as they have been prescribed, unless otherwise directed by the doctor who prescribed them. During the 25 hours or after if I (my dependent) get a life-threatening reaction, I need to seek emergency help immediately from a physician qualified in emergency treatments, or by calling 911 or visiting an emergency room at the local hospital. If I (my dependent) am suffering from severe allergic reactions to substances, I should consult an appropriate physician and take appropriate medication (such as medication to prevent itching, tissue swelling, fever, cough, pains, infections, mental irritability, violent behaviors, etc.) to keep my (my dependent's) symptoms under control while I (my dependent) am treated with NAET® treatments. This way essential NAET® treatments can completed without interruption and once I (my dependent) complete the essential NAET® treatments for my (my dependent's) condition, I (my dependent) may not need to continue pharmaceutical drugs indefinitely. I understand that for 25 hours after the treatment I (my dependent) am to avoid eating, touching, breathing and coming within 5 feet or more as it was instructed by my practitioner of the substance(s) that I (my dependent have received treatment for. If 1 (my dependent) come in contact with the substance(s) for which I (my dependent) am being treated, I realize that the treatment may not work and I (my dependent) may still have a sensitivity reaction. I understand that I (my dependent) must return after my 25 hour avoidance period to see if I (my dependent) have cleared the allergy/ sensitivity to the substance. I fully understand that I (my dependent) may still experience a reaction to the substance(s) of unknown severity if I (my dependent) did not clear them completely. I (my dependent) may be required to repeat the procedure (more office visits at my cost) until I (my dependent) clear them satisfactorily. I give permission to Allergy Free Naturally to use my (my dependent's) case study in educating other similar patients or accumulating data for research purposes without disclosing my real name or address. I give permission to take photograph(s) of my (my dependent's) diseased body part (i.e. in case of a skin problem, etc.) to use in research or patient educational purposes without disclosing my real name or address. I have read or have had the above statements read to me and have the opportunity to ask questions about its content and by signing below, I agree to the terms and procedures given by this clinic, Allergy Free Naturally. Date MM DD YYYY Printed name of person signing (Relationship to minor) Printed name of minor being signed for Thank you!
