Wellspring

clinic

Female Intake Form

Female Patient Intake Form

Name(Required)
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Address(Required)
Spouse/Partner
In the event we are unable to contact you by means you've provided above, we'd like to have the ability to contact you through your spouse. Please provide the necessary information about your spouse/partner below.
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Frequent = Many Times/Wk Occasionally = Weekly Rarely = Ever Few Weeks
What types of contraceptive are you currently using? (please check all that apply)
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How was it treated?
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Form:
Do you have/had hypertension?
Do you have heart disease?
Do you have diabetes?
Have you ever had a heart attack?
Have you ever had a stroke?
Have you ever been anemic?
Have you ever had hepatitis/liver disease?
Have you ever had any issues with local anesthesia, such as a that the dentist office?
Have you ever been treated for a psychiatric disorder?
Do you have thyroid problems?
Are you currently taking thyroid medications, or did you in the past?
Do you have arthritis?
Type of arthritis?
Have you had blood clots in your legs or lungs?
Do you have issues with water retention?
Do you have problems with bloating?
Do you have osteopenia or osteporosis?
Do you suffer from hair loss?
Do you suffer from acne?
Have you had blood clots in your legs or lungs?
Do you have a family history of heart disease?
Do you have a family history of Kidney Disease?
Do you have a family history of Osteoporosis?
Do you have a family history of Breast Cancer?
Do you have a family history of Ovarian Cancer?
Do you have a family history of Colon Cancer?
Do you have a family history of Diabetes?
Do you have a family history of Hypertension (high blood pressure)?

I understand that Dr. Nael Dagstani NMD is licensed as a physician by the State of Arizona Naturopathic Physicians Board of Medical Examiners.

I understand that Dr. Dagstani subscribes to the accepted standard of care for practices of diagnosing and treating the human mind and body utilizing various modalities that includes Botanical/Pharmacologic intervention, Homeopathy Clinical/Medical Nutrition, Parenteral (IV) nutrient therapy, Naturopathic Manipulative Therapy (NMT), minor surgical procedures, and other forms of hygienic and physiotherapeutic techniques.

I understand that Dr. Dagstani may use one or several of the above listed modalities for my treatment in accordance with our agreed upon care plan.

I understand I will not be involved in any research or experimental project without my full knowledge or consent.

I give my general consent for Dr. Dagstani to administer to my needs according to the standards of Naturopathic Medical training and practice in the State of Arizona.

I understand that my insurance generally will not pay for these services (although most will pay for any ordered radiologic or laboratory tests, and prescription medications depending on my plan), and that if I am part of an HMO or any Medicare, that Dr. Dagstani is not a participant in these plans specifically.

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Consent For Hormone Implantation

I authorize Dr.Nael Dagstani, NMD, to perform sterile minor surgical placement of hormone pellets under skin.

I understand the reason for the procedure is hormone therapy using estradiol and/or testosterone hormones.

I acknowledge that risks of this minor surgical procedure include possible infection and/or bleeding, among others.

LOCAL ANESTHESIA is used and involves risk, most importantly

PATIENT'S CONSENT: I have read and fully understand this consent form and understand I should not sign this form if all items, including all my questions, have not been explained or answered to my satisfaction or if I do not understand any of the terms or words contained in this consent form.

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Mammogram Waiver for Estradiol and Testosterone Pellet Therapy (if 40 years of age or older)

I voluntarily choose to undergo implantation of subcutaneous bioidentical Estradiol and/or Testosterone pellet therapy with Dr. Nael Dagnasti.

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I have not had a recent mammogram because:
Reasons:

I understand that mammograms are the best single method for detection of early breast cancer. I understand that my decision to forego a mammogram test may result in cancer remaining undetected in my body. I acknowledge that I bear full responsibility for any personal injury or illness, accident, risk or loss (including death and/or breast or uterine issues) that may be sustained by me in connection with my decision to refrain from obtaining a mammogram exam. I acknowledge and agree that I have been given adequate opportunity to review this document and to ask questions. I hereby release and agree to hold harmless Dr. Dagstani and any of his physicians, nurses, offices, directors, employees and against from any all liability, claims, demands and actions arising or related to any loss, property damage, illness, injury or accident that may be sustained by me as a result of my decision to forego a mammogram exam. This release hold harmless agreement is and shall be binding on myself and my heirs, assigns and personal representatives.

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Medicare and Medicaid Waiver

Acknowledgment and Agreement: This office does not accept or bill Medical or Medicaid. In exchange for the services, the Patient agrees to make cash (credit or debit card) payments to Wellspring Restorative Health. Patient also, agrees, understands and expressly acknowledges the following:

  • Patient agrees not to submit a claim (or a request that Physician submit a claim) to the Medicare program with respect to the services including, blood-work and laboratory services even if covered by Medicare Part B.
  • Patient is not currently in a an emergency or urgent health care situation.
  • Patient acknowledges that neither Medicare's fee limitations nor any other Medicare reimbursement regulations apply to charges for the Services.
  • Patient acknowledges that Medi-Gap plans will not provide payment or reimbursement for services because payment is not made under the Medicare program, and other supplemental insurance plans may likewise deny reimbursement.
  • Patient acknowledges that he has a right, as a Medicare beneficiary, to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare, and that the patient is not compelled to enter into private contracts that apply to their Medicare-covered services furnished by other physicians or practitioners who have not opted-out.
  • Patient agrees to be responsible, whether through insurance or otherwise, to make payment in full for the services including, blood=work and laboratory services, and acknowledges that Physician will not submit a Medicare claim for the services and that no Medicare reimbursement will be provided.
  • Patient understands that Medicare payment will not be made for any items or services furnished by tge physician that would have otherwise been covered by Medicare if there were no private contract and a proper Medicare claim were submitted.
  • Patient agrees to reimburse Physician for any costs and reasonable attorneys fees that result from violation of this Agreement by Patient or his beneficiaries.
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HIPPA - Health Insurance Portability and Accountability Act

YOUR RIGHTS- Under federal Health Insurance Portability and Accountability Act (HIPPA), you have the right to request restrictions on how we use or disclose your personal information for treatment, payment or health care operations. You also have the right to request restrictions on disclosures to family members or others who are involved in your health care or the paying of your care.

ACCESS TO YOUR PERSONAL HEALTH INFORMATION - You have the right to inspect and/or obtain a copy of your personal health information we maintain in your designated medical records. You must sign a release of medical records consent form to obtain these records.

FAMILY, FRIENDS, AND PERSONAL REPRESENTATIVES - With your written consent we may disclose to family members, close personal friends or another person you identify your personal health information relevant to their involvement with your care or paying for your care.

OTHER USERS AND DISCLOSURES - We are permitted or required by law to use or disclose your personal health information, without our authorization, in the following circumstances: For public health activities (reporting of disease, injury, birth, death or suspicion of child abuse, neglect, or other domestic violence)

  • To government authority if we believe an individual is a victim of abuse, neglect, or domestic violence
  • For health oversight activities (for example audits, inspections, licensure actions or civil, administrative or criminal proceedings or actions)
  • For judicial or administrative proceedings(i.e. Reporting wounds or injuries or for identifying or locating suspects, witnesses or missing persons)
  • To avert a serious threat to health or safety under certain circumstances
  • For military activities if you are a member of the armed forces or an inmate or individual confined to a correctional institution
  • For compliance with workers compensation claims

    • We will adhere to all state and federal laws or regulations that provide protections to your privacy. We will only disclose HIV/AIDS related information, genetic testing information and information pertaining to your mental condition or any substance abuse problems as permitted by law.

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