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ADOLESCENT PATIENT REGISTRATION FORM

ADOLESCENT PATIENT REGISTRATION FORM

* Patient's Name * M * Address F * Birthdate

* City

* State

* Zip

* Social Security Number

* Home Phone

* Mother's Name

* Mother's Cell Phone

* Mother's Work Phone

* Mother's Email

* Father's Name

* Father's Cell Phone

* Father's Work Phone

* Father's Email

* Referral Source

* Ethnicity Non Hispanic Hispanic Not Specified * Race

* Preferred Language

* Smoking Status

* Medications (include herbs, supplements and remedies)

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0/420 characters

* Drug Allergies (please list drugs and describe the allergic reaction)

0/420 characters

* Food/Environmental Allergies (Please list item and describe the reaction)

0/560 characters

* Current Medical Conditions (or symptoms,problems your child is currently experiencing)

0/420 characters

* Past Medical/Surgical History

0/560 characters

* Family History (list conditions that any relatives have had and state relationship to patient)

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0/560 characters

* Immunization History (please list vaccine/date)

0/420 characters

* Hospitalizations (please list reason and date)

0/420 characters

* Trauma History (list any mental, emotional or physical traumas with dates)

0/560 characters

* Never Well Since (list illnesses or treatments after which your child's level of health was never the same)

0/700 characters

* Concerns - please express any concerns you have about your child such as
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appearance,behavior,sexuality,school performance, friends,etc.

0/700 characters

* Hours per week your child spends on the computer, watching tv or playing video games?

* Do you suspect your child is involved with: Drugs you must have at least one item Alcohol Tobacco

* Have you noticed any of the following in your child? Angry behaviour Changes in Attitude Depression Skipping School you must have at least one item

* Changes in Appearance you must have at least one item Changes in Friendships Signs of Drugs in the House Withdrawal from Family/Friends

OFFICE POLICIES
New Patient Visits: First visits can take up to 1 hours. Depending on the patients needs, the emphasis will either be on homeopathy or osteopathy together with appropriate life-style recommendations. Please read the How To Report Symptoms page or the printed information which was sent to you by mail. Bring copies of recent laboratory work and other relevant medical reports as well as a list of all medications and supplements. If you are not using the online patient registration feature, please allow some extra time before your first visit to complete a patient registration form. The fees for a new patient visit are in the $425-$525 range. Initial visits for infants and children generally take less time and the fee is adjusted accordingly. Three business days notice is required to cancel a new patient visit. Fees for return visits vary based on the number and kind of procedures performed, generally in the $185- $265 range. Please call the office for details. Dr. Masiellos practice is office-based only, so patients are urged to maintain contact with conventional physicians for emergencies requiring hospitalizations, specialty consultation, surgery, diagnostic testing, gynecological services and routine cancer screening. He practices an integration of classical homeopathy and traditional osteopathy. Although homeopathy has been around for over 200 years, it is now considered to be alternative or nonconventional. Voice mail messages can be left 24 hours a day and he is available to established patients with urgent medical problems by cell phone.
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Health Insurance: We do not accept insurance payments nor do we participate in any networks or plans such as HMOs, PPOs, Workmans Compensation, No-Fault, Disability Plans or Medicaid. The practice is currently closed to new Medicare patients and patients on disability. Billing: Your treatment usually includes a medical office visit and an osteopathic treatment. As a courtesy, your claim will be submitted electronically on your behalf. If you do not have insurance, you will be given a receipt for tax purposes without insurance codes. Payment: Charges for all components of your treatment are due at the time of your visit. Cash, personal checks and credit cards (Master Card, Visa) are accepted. Patients are responsible for charges even if their deductible has not been met. There is no charge for a single dose of a remedy (pellets) dispensed at the time of the office visit. There is a fee for tinctures, liquid remedies and remedy tablets. A separate receipt will be issued for medication charges. Discount: There is a 15% discount for patients without health insurance or who are part of a network and will not get reimbursed for seeing a non-network physician. Discounted patients will receive a receipt without insurance codes for tax purposes. Receipts: Receipts for tax purposes are provided for patients without insurance. As a courtesy, all claims for patients with insurance will be submitted electronically. Cancelled or Missed Appointments: There is a fee for a missed office visit or for visits cancelled within less than 24 hours. Monday appointments must be cancelled on the previous Friday to avoid a cancellation fee. Lateness: The methods Dr. Masiello uses are labor-intensive and require the allotted time to complete so please maximize your experience by being on time. If you are late for your appointment and if the next patient has arrived early, the next patient may be seen during your appointment time in an effort to preserve the rest of the days schedule and not shortchange any one patient. Phone Consultations: Phone consultations are only for established patients who need homeopathic prescribing on weekends or after office hours. Phone consultations are not meant to replace an office visit. There is a $75 fee for phone consultations. Payment by credit card is required for the consultation. If the remedy prescribed during the phone consultation has not worked, you will be asked to come to the office for treatment the next day the office is open. The $75.00 fee will be deducted from the office visit fee so you will not pay twice for the same episode. Remedy kits for home prescribing are available via a link from this website. A Word About Fees: Dr. Masiello is dedicated to making holistic medicine available at a reasonable cost. He has set his prices at or below the fees listed in the Fair Health database. Return visits are based on the patients individual response to treatment and not on a fixed schedule. Homeopathy and osteopathy are used together to make the process time efficient and cost effective. The interval between visits increases as the patient responds to homeopathic remedies in the high potency range.

I understand that I am financially responsible for all charges, including any balance remaining after payment of health insurance benefits. I give my permission to release information needed for processing any health insurance claims.

* I have read and agree to the above office policies I agree * Indicates Response Required

Submit
Holistic Family Medicine, LLC
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141 East 55th Street New York, NY 10022 212-688-4848

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