Membership Agreement– We are a membership based office that provides a unique pediatric experience. This form is the agreement that is signed for joining the membership.
Comprehensive Evaluation Form– This form is a detailed history to assist our provider in getting to the root cause of what is causing your child’s symptoms. It is not required for all new patients, only those who have a chronic illness that they wish to have a functional medicine consultation for. We know it is long and detailed, but it is very valuable for evaluating and treating your child. It is a fillable form, so you can complete the form and email it to us (or fax if you choose).
Forms for your Reference
Notice of Privacy Practices– this form describes how your protected health information is protected and utilized.
Vaxcare Notice of Privacy Practices – Vaxcare is a third party company that provides and bills for commercial vaccines. If you have commercial insurance (BCBS, Aetna, United Healthcare, etc), Vaxcare will be doing the billing.