Forms | Resources | Dr. Debby Hamilton

Adult Medical Intake and Consent Forms

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Date of Initial Visit

MM slash DD slash YYYY

How did you hear about us:

PERSONAL INFORMATION

Name:(Required)

First Last

Date of Birth

Month

Day

Year

Gender

Female

Male

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Work Phone

Fax Number

Email(Required)

Enter Email Confirm Email

Occupation

CURRENT MEDICAL HISTORY

Please describe your primary concerns for this visit:

How long have you had these concerns?

Current Medical illnesses: (ex; Migraines, allergies, asthma, autoimmune disease, etc.)

Significant symptoms experienced regularly: (ex: stomach pains, headaches, yeast infections, etc.)

Past medical history: Medical illnesses including any hospitalizations (diabetes, arthritis, etc.)

Previous Surgeries:

Surgery

Date(s)

Results

Current Supplements:

Name of Supplement

Dose

Frequency

Current Prescription Medicines:

Name of Medication

Dose

Frequency

Year Started

Previous Prescription Medicines:

Name of Medication

Dose

Frequency

Year Started

Year Finished

Any Known Drug Allergies:

Yes

If so, which medicines:

Previous Antibiotic Use:

Name of Medication

Number of times prescribed

Any long-term antibiotic use: (ex: for acne, prevention of infection)

Yes

Please list previous treatments (other than medications) and results from these treatments (example: special diets, acupuncture, etc.):

Treatment

Results

Please list any relevant laboratory studies and results:

Labs

Results

FAMILY HISTORY

List any allergies, major illnesses, genetic diseases or problems for each of the following family members of your child:

Mother:

Father:

Siblings:

Children:

Others:

ENVIRONMENTAL HISTORY

Check the appropriate answers to the following questions.

Location of home:

CIty

Suburban

Wooded

Farm

Other

Other (describe):

Water:

CIty

Well

Purification system:

Yes

If yes, please describe:

Type of heat:

Electric

Gas

Oil

Other

Other (describe):

Do you live near:

Power lines

Woods

Industrial areas

Water

If you live near water, list type:

Swamp

River

Ocean

Other

Other:

Does your home have a lot of: Dust/mold/down or feather items (pillows, upholstery, stuffed animals)? If so please give details:

Describe your bedroom (Check all that apply)

Bedding: Synthetic

Bedding: Down

Bedding: Feather

Mattress Cover: Yes

Mattress Cover: No

Flooring: Carpet (wall-to-wall)

Flooring: Carpet (area rug)

Flooring: Wood

Flooring: Glued down

Flooring: Synthetic pad

Window treatment: Shades

Window treatment: Blinds

Window treatment: Thin curtain

Window treatment: Heavy curtain

Window treatment: Valance

Other

Other:

Are you bothered by any of the following? Please check where appropriate:

Perfumes/cosmetics

Cleaning products

Soaps/Detergents

Dust

Mold

Pollens/grasses

Animals (dander)

Gasoline

Paint

EMT's

Other

Please list known allergies:

Office Policies for Dr. Debby Hamilton

APPOINTMENTS: Your first consultation will be scheduled for 60 minutes. For more chronic or complicated problems, the first consultation may be up to 90 minutes.

CONSULTATION FEES: Payment is expected at the time of the visit. Health insurance reimbursement forms will be given to submit to your insurance company at the end of the visit. For Phone or Zoom consults, payment will be charged on the day of the visit.

Consults: $280 for 1 hour, $420 for 1½ hours

CANCELLATION POLICY: Cancellation fee if less than 24 hours before time of scheduled visit: $100

PHONE CALLS/PHONE CONSULTATIONS: Questions that can be answered within 10 minutes will not be charged. For lengthier concerns, laboratory results, or follow-up visits: phone calls will be charged as a consult.

Dr. Debby’s practice is a consult only practice for chronic health conditions. Because of this, she does not do primary care, emergency visits, or emergency phone calls. Patients need to have a primary care physician for primary care and emergency visits and phone calls.

Financial Responsibility:

I hereby agree to accept full responsibility for all fees for service rendered to the patient by the practitioner.

E-Mail and Fax Consent:

I give my permission for information to be transmitted to me by e-mail and fax. I understand and hold harmless Dr. Debby Hamilton and her employees from any liability, claim, or damages arising out of technical problems.

My signature below is an acknowledgement that I have read and fully understand the office policies listed above.

Patient's Name

First Last

Parent's Name

First Last

Date

MM slash DD slash YYYY

Authorization and Consent for Treatment

Acknowledgement of the Use of an Integrative Approach to Medical Care

This document is a binding contract setting forth the obligations I assume in consideration for the medical care and treatment to be provided to me. I as the patient or parent/legal caregiver agree to be bound by its terms.

I have specifically sought out the services and perspective of the providers at Holistic Pediatric Consulting for their integrative approach to medicine, drawing on Traditional and Holistic/Integrative Medicine methods. I have sought out my provider because I know that she is knowledgeable in both conventional and unconventional methods of treating illnesses and draws upon this experience and expertise to individualize and customize a treatment plan for each patient depending on the presentation. I understand that I will be presented with treatment options that include traditional and integrative approaches, and that ultimately, I will make the final decision on which method of treatment is right for me and my family.

Testing and/or treatments that may be offered or recommended by your provider at Holistic Pediatric Consulting may include, but are not limited to: Personalized Nutritional Support and/or testing, Allergy testing,, Detoxification evaluation and support, Vitamin and Mineral supplementation, Herbal Therapy, Essential Oil Therapy, Comprehensive Stool Analysis, General Laboratory Screening, Organic Acid Testing, Infectious disease testing and treatment

I have read this form that serves as an informed consent document and an authorization and have been given the opportunity to ask questions. If I have questions later, I understand I can contact a provider at Holistic Pediatric Consulting. I will be given a signed copy of this document for my records.

BY COMPLETING AND SUBMITTING THIS FORM, I AGREE THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE INFORMATION, THE ELEMENTS OF MY INFORMED CONSENT, MY RIGHTS AND RESPONSIBILITIES, AND HEREBY GIVE CONSENT TO UNDERGO TREATMENT AT HOLISTIC PEDIATRIC CONSULTING.

Patient's Name

First Last

Parent's Name

First Last

Date

MM slash DD slash YYYY

Patient or Parent signature

There is so much research out there for what to do when pregnant but not as much out there for what to do before becoming pregnant. This information was just overall great information for general health. It was important to my husband and I to get our bodies prepared for pregnancy in order to provide a healthy environment for the baby to grow. I can’t thank you enough-this course was the best thing I’ve done in a long time!

K.J., Louisville, CO

Contact Dr. Debby

drdebby@holisticpediatric.com

This website is not designed to and does not provide medical advice, diagnoses, treatment or services. Dr. Debby Hamilton provides information for education from this site and from links to other websites. This information is not a substitute for professional medical care. Dr. Debby Hamilton is not liable for any personal medical advice taken from this website or one of its links.