Bainbridge Naturopathic Clinic



BAINBRIDGE NATUROPATHIC CLINICDr. Christina Hinchcliffe, ND727 Ericksen AVE NE, Ste 220Bainbridge Island, WA 98110P: (206)842-4841 / F: (206) 388-4143/ Welcome to Bainbridge Naturopathic Clinic. We will do our best to serve your healthcare needs, provide natural and safe treatments, and serve as a resource for natural health education. It is important to us that you read and understand our clinic policies. If you have questions about the policies, please be sure to ask. We encourage you to communicate any issues, complaints or special needs with us.CLINIC POLICIESPAYMENT Payment is due at the time of service for office visits (non-insurance if deductible has been met), copays and dispensary items. We accept cash, checks, debit cards, health savings account (HSA) cards, Visa, Mastercard, and American Express. Payment plans and sliding scales are available upon request. INSURANCE It is your responsibility to make sure that your insurance policy covers the treatment you are receiving. Please call your insurance company before your visit and get specific information regarding your policy coverage.If you are unable to find this information, please ask us and we can help you make sense of your insurance. Please do this before your appointment to avoid unnecessary costs. There are treatments we may do that aren’t covered by insurance, in which case you will be responsible for payment. We will try to let you know before we perform any “uncovered services,” but they vary from plan to plan and sometimes we are unaware that a specific plan won’t pay, in which case it will be your responsibility. I understand that I am financially responsible for all charges and agree to pay for services. If applicable, I authorize the provider to release to my insurance company any information necessary to process a claim. I authorize the insurance payment be made directly to the provider. Initials __________Date __________ SUPPLEMENTS We stock a dispensary in our office and will recommend items that you can buy here. However, we may also recommend you go elsewhere and you are not obliged to purchase directly from Bainbridge Naturopathic Clinic. When you need refills, please call a few days ahead to make sure we’ve got your items in stock. Sometimes, due to vendor back orders or other circumstances, we will not be able to get the same item and will give you a similar product as a substitute. If you need to pick items up when we are not in the office, we have a pick-up box outside of the clinic where we will leave items for you when appropriate. CONTACT US We prefer to be contacted via our main phone at (206) 842-4841 or fax (206) 388-4143. You can also email for general information at info@. However, we cannot provide confidential information via this email address. You can also send emails to doctorhinchcliffe@ and Dr. Hinchcliffe can send you a confidential secure reply. Dr. Hinchcliffe has appointment times available on Tuesdays, Wednesdays and Fridays from 9-5, except for lunch break between 12-1. Nicole, our office manager, is in the office from approximately 8:30-3:30 Tuesday-Fridays. We also have an answering service that helps manage our call volume.If you have an urgent need to reach us after hours or during off days, follow the steps on the voicemail prompt at our regular phone number of (206) 842-4841 in order to reach us. CANCELLATION POLICY We are a small clinic and do our own scheduling. We appreciate if you give us at least 48 hours notice before canceling an appointment so we have sufficient time to fill that spot. Since we dedicate 30 minutes to 1 hour of our time for your appointment, an empty time spot as a result of your late cancellation can hurt our business. For this reason, if you cancel your appointment with less than 48 hours notice, there is a $50.00 charge for your empty time slot. This is charged to you, not your insurance. The charge will only be waived in emergency situations. I have read and understand that if I cancel within 48 hours of an appointment, I will be liable for a $50.00 cancellation charge. Initials __________Date __________ NO SHOW POLICY If you make an appointment and don’t call or show up for that appointment (barring emergency situations in which a call cannot be made) there is a charge of $50.00. This is charged to you and not your insurance. We reserve the right to discontinue care to patients who no show and/or have a late cancellation for three appointments. I have read and understand the “No Show” policy and understand that if I fail to show up at my scheduled appointed time, I will be charged $50.00. Initials __________Date __________ CONFIDENTIALITY You have the right to know how your privacy is being protected in accordance with the HIPAA Act of 1996. Your healthcare information is private and cannot be shared with anyone else without your signed consent. Your records are kept in your chart and secured in our clinic at all times. If information regarding patients is in the open, names are covered. Access to the clinic is limited to practitioners, employees, and supervised guests. I have read and understand my right to privacy, as stated above, and agree to allow Bainbridge Naturopathic Clinic to maintain my records confidentially in accordance with the law.Initials _________ Date __________NEW PATIENT INTAKE FORM PATIENT INFORMATION Name _____________________________________ Date of Birth __________________ Age________ Address ___________________________________ City _______________ State _____ Zip _________ Home Phone ______________________ Cell_____________________ Work_____________________ Email ______________________________________ Social Security Number ______________________ Relationship Status: _____Married/Partnered _____Divorced/Separated _____Single/Widowed Live with: ____Spouse ____Partner ____Relative/s ____Friend/s ____Parent/s ____Kid/s ____Pet/s Emergency Contact ___________________________ Phone ___________________________________ How did you hear about us? ______________________________________________________________ Would you like to receive a copy of Dr. Hinchcliffe's bimonthly newsletter and updates on her blog posting via email? Y / NEMPLOYMENT INFORMATION Employer _______________________________________ Position ______________________________ Address ________________________________________ Phone ________________________________ INSURANCE INFORMATION Insurance Company/Plan Name ___________________________________________________________ ID Number/Claim Number ________________________________ Group Number _________________ Insurance Phone ____________________ Whose Policy is this (circle): Self Spouse Other(If not self, please list name & date of birth of policy holder) ____________________________________ It is your responsibility to familiarize yourself with your insurance policy. If you are unsure whether you have naturopathic coverage, please call your insurance company or check online to verify. It is important to know if you have a deductible, if you have preventative care coverage, and which labs are covered by your insurance. Copays are due at the time of service. Supplements are not covered by insurance. _____ (initial) I understand that I am financially responsible for all charges and agree to pay for services not covered by insurance. _____ (initial) I authorize the provider to release to my insurance company or companies, any and all information necessary to process any claim. I further authorize that payment/s be made directly to the provider. CONFIDENTIALITY You have the right to confidentiality when receiving care from providers. We will not disclose medical information to anyone unless directed to do so in writing by you. If you would like us to leave messages regarding your health care on an answering machine or with another person, please list them below and/or indicate which voice mail we may leave messages on: _____________________________________________________________________________________ Initials _________ Date __________YOUR CURRENT HEALTH What is your main reason for coming in today? ______________________________________________ __________________________________________________________________________________________________________________________________________________________________________MEDICAL HISTORY What childhood illnesses have you had? ____________________________________________________ __________________________________________________________________________________________________________________________________________________________________________What adult illnesses have you had? ________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________Previous surgeries and hospitalizations (include approximate dates): _______________________________________________________________________________________________________________________________________________________________________________________________________Do you have any allergies to any drugs, herbs, foods, animals or other? _____________________________________________________________________________________________________________________________________________________________________________________________________ CURRENT MEDICATIONS/SUPPLEMENTSPlease list any medications, vitamins, herbs, supplements, or over-the-counter products you are taking: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ PATIENT SIGNATURE _____________________________________________ DATE ________________ FAMILY HISTORY OF HEALTH PROBLEMS (and age of death, if applicable) Your Mother __________________________________________________________________________Your Father ___________________________________________________________________________ Your Siblings __________________________________________________________________________ Maternal Grandparents _________________________________________________________________Paternal Grandparents _________________________________________________________________Children ______________________________________________________________________________ PERSONAL HABITSWhat do you enjoy most in your life? ______________________________________________________ What are your main interests or hobbies? ___________________________________________________ Do you regularly use alcoholic beverages, how much? _________________________________________ Do you smoke (how much & for how long)? ________________________________________________ Do you use recreational drugs (which & how much)? __________________________________________ How often do you watch television? _______________________________________________________ Do you have a religious or spiritual practice? ________________________________________________ Do you enjoy your work? _____________________ Do you take vacations? _______________________ Do your work or hobbies expose you to toxic chemicals, heavy metals, mold or second hand smoke?STRESS On a scale of 1-10 (10 being high), how do you rate your average stress level? 0 1 2 3 4 5 6 7 8 9 10 What are the most significant stressors in your life or areas of disharmony? SLEEP On a scale of 1-10 (10 being great), how do you rate your sleep? 0 1 2 3 4 5 6 7 8 9 10 Do you have problems falling or staying asleep (which)? _______________________________________ How many hours do you sleep at night? ____________ Do you awaken refreshed?__________________ENERGY On a scale of 1-10 (10 being great), how do you rate your energy? 0 1 2 3 4 5 6 7 8 9 10 Are your daily tasks affected by your being tired? ____________________________________________EXERCISE What type, how much, & how often do you exercise? _________________________________________DIET Do you follow a special diet? _________________Do you eat at least 3 meals a day? ________________ Are you satisfied with your diet? ______________How much water do you drink daily? ______________ Do you drink soda or juice? N / Y, How much? _______________________________________________ Do you take in caffeine? N / Y, How much? _________________________________________________ Please list the foods/amounts you’ve eaten in the past 24 hours: ________________________________ __________________________________________________________________________________________________________________________________________________________________________PATIENT SIGNATURE _____________________________________________ DATE _________________ HEALTH CONCERNS (Please circle all items that are current or recent) GENERAL: fever, night sweats, fatigue/tiredness, unusual weight gain or weight loss, appetite changes, eating disorder, poor sleep, strong thirst, cravings, swelling of lymph nodes, food sensitivities or allergies, cancer (if yes, what type ______________)SKIN, HAIR, NAILS: rash, infection, growths/bumps, hair loss, itching, thinning/sensitive skin, acne, oily, sores/lesions, eczema, sensitive skin, nail infection, dry hair, thin/brittle nails, ridged nailsHEAD, EYES, EARS, NOSE, THROAT: frequent headaches, migraines, vision problems, eye pain, double vision, floaters/spots, eye redness/watery eyes, tearing problems, hearing loss, ringing, earache or ear pain, itchy ears, hearing aids, frequent colds or flus, sinus problems or drainage, post nasal drip, hay fever/allergies, loss of taste or smell, snoring, frequent sore or dry throat, hoarseness, sore or swollen tongue, mouth or lip sores, dental problems, TMJCENTRAL NERVOUS SYSTEM: head injury, light-headedness, dizziness, convulsions, weakness/paralysis, balance disturbance, trouble speakingMUSCULOSKELETAL: joint or muscle pain/stiffness (if yes, where_____________), injury, muscle cramps/spasms, muscle weakness, bone loss, loss of muscle massPERIPHERAL NERVOUS SYSTEM: loss of sensation or feeling in a body part, pins and needles sensations in a body partCARDIOVASCULAR AND CIRCULATION: chest pain or discomfort, high blood pressure, heart murmur, palpitations, swelling, leg swelling, dizziness, history of heart attack or TIA/stroke/blood clots, history of angina/chest pain, history of rheumatic fever, easy bruising, tendency to bleed easily or difficulty stopping bleeding, nose bleeds, high cholesterol, varicose veins, spider veins, discolored extremities, paleness, anemiaRESPIRATORY: cough, sputum, wheezing/asthma, chest pain, shortness of breath, rib painDIGESTION: heartburn, ulcer, abdominal pain, nausea, vomiting, blood/food/mucus/oil in stools, black tarry stools, abdominal bloating, belching, excessive gas, bad breath, coating on tongue, hemorrhoids, hepatitis, polyps, constipation, diarrhea, last colonoscopy (and results) _______GENITOURINARY: pain with urination, urgency, frequency, dribbling, incontinence, bladder infections, cloudy/foul smelling urine, kidney stones, blood in urine, urinating at night (if yes, how often?_______), hernia, lower abdominal pain, sexually transmitted disease, urethral or genital discharge, genital soresMALE: prostate inflammation, erectile difficulties, testicular pain or swelling, last digital prostate exam (and results) _______, last PSA blood test (and results) ______MENTAL-EMOTIONAL: depression, mood swings, anxiety, irritability, tearfulness, nervousness, tension, phobias, compulsive behaviors, psychiatric disorder, suicidal thoughts/plan, diagnosed with or possible alcohol/drug dependency, worry, relationship problems, abusive relationship, elevated stress, ADD/ADHDENDOCRINE: low thyroid function, overactive thyroid function, enlarged thyroid, thyroid with nodules, low temperature, hot flashes, diabetes, low blood sugar, high blood sugar, sugar or salt cravings, difficulty perspiring, rapid agingFEMALE: heavy bleeding, painful bleeding, clots, PMS, PCOS, infertility, lack of bleeding, irregular cycles, odor, itching, painful intercourse, sexual dysfunction, breast pain/lumps, lack of sex drive, fibroids, ovarian cysts or PCOS, abnormal hair growth, birth control pills or injections, vaginal dryness, hysterectomy (total or partial?), age of first period ___, age of last period___, number of pregnancies___, number of children (ages) ___________________, last pap (and results) ____________, last breast imaging (and results) ____________, last bone density scan (and results) ____________PATIENT SIGNATURE _____________________________________________ DATE ________________ FINAL SIGNATURE/STATEMENT“I__________________________________ have asked Dr. Christina Hinchcliffe, ND, of Bainbridge Naturopathic Clinic, for help and I understand that the doctor will help to the best of her ability.”PATIENT SIGNATURE _____________________________________________ DATE ________________ DOCTOR SIGNATURE _____________________________________________ DATE ________________ ................
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