Golden Naturopathic Clinic, LLC

                                    PATIENT INFORMATION

 

Patient Name: __________________________________________________________________Date:___________

Male / Female _________________________________________________ DOB:___________________________

Email Address:___________________________________________________________________________________

Would you like to receive:   Periodic updates about the Clinic by email? Yes___  No____     

Address:_________________________________________________________________________________________

City:_____________________________ State ________________________________ZIP code_________________

Home Phone #________________________ Work #____________________ Cell #:_______________________

Patient Employer________________________________________: Phone #______________________________

Employer’s Address:____________________________________________________________________________

City State ZIP code______________________________________________________________________________

Person Responsible for Bills:      (  ) Self      (  ) Parent      (  ) Legal Guardian

Spouse/ Parent / Guardian:_________________________________________ Phone:_____________________

Emergency Contact: ________________________________________________Phone:______________________

Relationship:_____________________________________________________________________________________

Drug Allergies: Yes   /   No Please List:____________________________________________________________

Who may we thank for referring you?    _________________________________________________________ 

Note: All professional services rendered are charged to the patient. The patient is responsible for all fees, regardless of private or group insurance coverage. Fees are payable when service is rendered. Special arrangements must be made in Advance of service. Missed appointments are subject to a $75 fee.

 

I have read the fee and payment policy statements and understand that I am fully responsible for fees incurred by me at Golden Naturopathic Clinic, LLC

________________________________________________            ____________

Signature:                                                                            Date: 

 

 

 

                                                                  Release Form

 

Dear Patient:

 

Please be advised that if you receive treatments or therapies by a practitioner of Golden Naturopathic Clinic, LLC, the clinic cannot guarantee any portion of a treatment or therapy will be covered by your insurance, and you are responsible for all charges at the time of service.  You will be provided a transmittal sheet with appropriate coding so you can submit to your insurance provider for reimbursement.

 

Charges are as follows:

New Patient 90 minute appointment: $250

Follow Up 60 minute appointment:     $150

Follow up 30 minute appointment:      $75

Craniosacral therapy 60 minutes:         $100

4-pack Craniosacral Therapy:                $320

 

Labwork and supplement costs are not included in this list of charges.

 

You have the right to refuse treatment or therapy if you are not willing or able to pay for the treatments.  You also have the option to refuse service if you do not want treatments for any reason other than financial.

 

If you have any questions, please ask at the front desk.

 

Thank You

 

Golden Naturopathic Clinic, LLC

 

_______________________________________          ___________________

 

Patient Signature Date

 

 

        Golden Naturopathic Clinic, LLC

Kaycie Rosen Grigel, Registered ND

Colorado Registration number: 62

PO Box 97, Golden, CO 80402

P: 303.704.2649  F:720.475.1536

drkaycierosen@gmail.com

http:// goldenholisticmedicine.com

 

Disclosure Statement and Consent for Treatment

Dr. Rosen Grigel is registered in the State of Colorado and commonly provides the following services:

• Diagnostic procedures including ordering labwork and imaging as well as gynecological exams.
• Routine Physical exams
• Dispensing and recommending non-prescription medications, homeopathics, botanicals, and dietary supplements.
• Hands-on Naturopathic techniques of bodywork

Complaints regarding Dr Rosen Grigel must be submitted in writing to the Office of Naturopathic Doctor Registration. To obtain a complaint form, please contact the Division at (303)894-7414 or find more information how to file a complaint at: http://www.dora.state.co.us/reg_investigations/file_complaint.htm.

Naturopathic Doctors are registered by the state to practice naturopathic medicine under the “Naturopathic Doctor Act.” They are not permitted to perform the following acts:

• Prescribe, dispense, administer or inject any prescription medications or devices other than epinephrine for anaphylaxis, barrier contraceptives (not including IUDs), and Vitamins B12 and B6
• Perform general surgical procedures, including surgical procedures using a laser device other than minor office procedures for wound suturing
• Use general or spinal anesthetics, other than topical and local anesthetics.
• Administer ionizing radioactive substances for therapeutic purposes.
• Treat a child unless: (1) this form is fully completed and signed; (2) the most recent immunizations schedule recommended by the advisory committee on immunization practices to the CDC and prevention in the federal department of health and human services is provided to the parent or guardian with this form; and (3) a release of information is provided to the parent or guardian requesting permission to exchange information with the child’s licensed pediatric health care provider, if the child has one.
• Practice any form of healing other than Naturopathic Medicine.
• Practice obstetrics.
• Perform chiropractic services (spinal adjustments, manipulation, or mobilization). Physical medicine, as described in § 12-37.3-102(12)(b), C.R.S., is permitted.
• Recommend the discontinuation of or counsel against a course of care, including a prescription drug that was recommended by another health care practitioner licensed in Colorado, unless the Naturopathic Doctor consults with the health care practitioner.

 

 

 

Disclosure Statement  

1. I, Kaycie Grigel, am a Naturopathic Doctor registered under Title 12, Article 37.3, of the Colorado Revised Statutes., and not a medical doctor or a physician licensed under Title 12, Article 36, of the Colorado Revised Statutes.
2. I recommend that the patient named below have a relationship with a licensed physician.
3.   If the patient is a child, I recommend he or she maintains a relationship with a licensed pediatric health care provider, and that the child’s parent or guardian follow the immunizations schedule that can be found at: http://www.cdc.gov/vaccines/parents/downloads/parent-ver-sch-0-6yrs.pdf
4. If the patient has a relationship with a licensed physician or pediatric health care provider, I will attempt to develop and maintain a collaborative relationship with the physician or pediatric health care provider with the permission of the patient.

_________________________________________                                     ____________

Kaycie Rosen Grigel, RND                                                                          Date

Acknowledgement and Consent for Treatment (to be completed by the adult patient, or parent/guardian if patient is a minor)

I, __________________________________________, acknowledge receipt of the above disclosure statement and give my informed consent for treatment for (circle one) myself or my child, __________________________________________ (print patient’s name) by Dr Rosen Grigel.

Check one:

The patient ___ does ___ does not have a relationship with a licensed physician or pediatric health care provider and would like Dr Grigel to contact this provider.

Name, address, phone of licensed physician or pediatric health care provider:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

 

I, ________________________________________(patient or guardian’s name) authorize the release of my records to the above provider from the Golden Naturopathic Clinic, LLC

 

____________________________________                                  _________________

Signature of Patient/Parent or Guardian                                  Date

(This form must be completed and signed prior to the initial examination of the patient.)