Wufoo

Name * First Last
DOB * MM / DD / YYYY
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Number * ### - ### - ####
Cell Number * ### - ### - ####
Email *
Emergency Contact * First Last
Phone Number * ### - ### - ####
Relationship *
Reason For Visit *
Last Physical Exam *
Allergies / sensitivities *
Are you in Frequent contact with harmful chemicals? *
Yes No
List major causes of stress *
Level of Stress *
1 2 3 4 5

1 being no stress and 5 being high stress
How did you hear about us or who referred you? *
PATIENT HIPAA CONSENT FORM

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:
• Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
• Obtaining payment from third party payers (e.g. my insurance company);
• The day-to-day healthcare operations of your practice.
• Consent to mailing of patient birthday cards to the patients listed address in chart.
• Consent to display gifts and or cards given to staff and doctors in office.
• Consent to emailing of newsletters and clinic updates to the patients listed email address in chart.
• Consent to leave voicemails regarding appointments, and patient information at listed phone number in chart.
• Consent to talk to someone other than patient regarding treatment and appointments. YES OR NO (If yes, please list approved personal and relationship).
Do You Give Consent? *
Yes No
Approved List of Individuals Whom We Can Talk To Regarding Treatment and Appointments
Person
Relationship
Person
Relationship
Person
Relationship
I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.
Date MM / DD / YYYY
Patient Name *
Signature *
Relationship To Patient

If you are the patient, you may leave this blank
Consent Waiver

Naturopathic services at this facility are supervised by a licensed medical doctor in the State of Georgia. Quantum Healthworks Inc. D.B.A., Genesis Health Center or “The Genesis Center” and its employees do not recommend or dispense prescription drugs unless prescribed by the supervising medial doctor.

Quantum Healthworks Inc./D.B.A. Genesis Health Center or The Genesis Center provides naturopathic services to private persons by contract. Article I if the Constitution of the United States of America guarantees the right to contract. Additionally, we provide nonprescription health products for sale to private persons with whom we contract.

“Naturopathy is hereby defined as the philosophy and system of healing art embracing prevention, and recommendations of human ills and functions by the use of several properties of air, light, heat, cold, water, manipulation, with the use of such nutritional substances as are naturally found in and required by the body excluding drugs, surgery, x-ray, radium therapy, and the use of x-ray equipment.”

I have read the above and understand it. I choose to have Quantum Health Works Inc./D.B.A., Genesis Health Center or the Genesis Center provide me with naturopathic services. I consent to allow my records to be reviewed by the clinics supervising medical doctor. Furthermore, I understand that naturopathy is a system of health care that supports the body’s ability to heal and regenerate itself. I understand that this clinic and its employees have made no promise regarding a cure for any disease or illness whatsoever. In addition, we require that you continue to maintain your regularly scheduled appointments with your Primary Care Physicians and Medical Specialist.
Patient Signature *
Email *
Date MM / DD / YYYY
Do Not Fill This Out

Wufoo

PATIENT HIPAA CONSENT FORM

Approved List of Individuals Whom We Can Talk To Regarding Treatment and Appointments

Consent Waiver