Golden Naturopathic Clinic, LLC

                                     PATIENT INFORMATION

Patient Name:                                                                        Date:                

Male / Female                                                                        DOB:                

Email Address:                                                                        

Would you like to receive:   Periodic updates about the Clinic by email? Yes___  No____    

Address:                                                                                        

City:                                                         State                 ZIP code                

Home Phone #                                Work #                        Cell #:                        

Patient Employer:                                                        Phone #                

Employer’s Address:                                                                                

City                                                         State                 ZIP code                

Person Responsible for Bills:                (  ) Self        (  ) Parent        (  ) Legal Guardian

Spouse/ Parent / Guardian:                                                Phone:                        

Emergency Contact:                                                        Phone:                        

Relationship:                                                

Drug Allergies:        Yes   /   No        Please List:                                                

Who may we thank for referring you?                                                            

________________________________________________            ____________

Signature:                                                                Date:                        


Release Form

Dear Patient:

Please be advised that if you receive treatments or therapies by a practitioner of Golden Naturopathic Clinic, LLC, the clinic cannot guarantee any portion of a treatment or therapy will be covered by your insurance, and you are responsible for all charges at the time of service.  You will be provided a transmittal sheet with appropriate coding so you can submit to your insurance provider for reimbursement.

Charges are as follows:

New Patient 90 minute appointment: $250

Follow Up 60 minute appointment:     $150

Follow up 30 minute appointment:      $75

Craniosacral therapy 60 minutes:         $100

4-pack Craniosacral Therapy:                $320

Note: All professional services rendered are charged to the patient. The patient is responsible for all fees, regardless of private or group insurance coverage. Fees are payable when service is rendered. Special arrangements must be made in Advance of service. Missed appointments are subject to a $75 fee.

Labwork and supplement costs are not included in this list of charges.

You have the right to refuse treatment or therapy if you are not willing or able to pay for the treatments.  You also have the option to refuse service if you do not want treatments for any reason other than financial.

If you have any questions, please ask.  

Thank You

Golden Naturopathic Clinic, LLC

I have read the fee and payment policy statements and understand that I am fully responsible for fees incurred by me at Golden Naturopathic Clinic, LLC

_______________________________________          ___________________

Patient Signature                                                 Date

 Golden Naturopathic Clinic, LLC

Kaycie Rosen Grigel, ND

Colorado Registration number: 62

PO Box 97, Golden, CO 80402

P: 303.704.2649  F:720.475.1536

drkaycierosen@gmail.com

http:// goldenholisticmedicine.com

Disclosure Statement and Consent for Treatment

Dr. Rosen Grigel is registered in the State of Colorado and commonly provides the following services:

Complaints regarding Dr Rosen Grigel must be submitted in writing to the Office of Naturopathic Doctor Registration. To obtain a complaint form, please contact the Division at (303)894-7414 or find more information how to file a complaint at: http://www.dora.state.co.us/reg_investigations/file_complaint.htm.

Naturopathic Doctors are registered by the state to practice naturopathic medicine under the “Naturopathic Doctor Act.” They are not permitted to perform the following acts:

• Prescribe, dispense, administer or inject any prescription medications or devices other than epinephrine for anaphylaxis, barrier contraceptives (not including IUDs), and Vitamins B12 and B6

• Perform general surgical procedures, including surgical procedures using a laser device other than  minor office procedures for wound suturing

• Use general or spinal anesthetics, other than topical and local anesthetics.

• Administer ionizing radioactive substances for therapeutic purposes.

• Treat a child unless: (1) this form is fully completed and signed; (2) the most recent immunizations schedule recommended by the advisory committee on immunization practices to the CDC and prevention in the federal department of health and human services is provided to the parent or guardian with this form; and (3) a release of information is provided to the parent or guardian requesting permission to exchange information with the child’s licensed pediatric health care provider, if the child has one.

• Practice any form of healing other than Naturopathic Medicine.

• Practice obstetrics.

• Perform chiropractic services (spinal adjustments, manipulation, or mobilization). Physical medicine, as described in § 12-37.3-102(12)(b), C.R.S., is permitted.

• Recommend the discontinuation of or counsel against a course of care, including a prescription drug that was recommended by another health care practitioner licensed in Colorado, unless the Naturopathic Doctor consults with the health care practitioner.

Disclosure Statement  

1. I, Kaycie Grigel, am a Naturopathic Doctor registered under Title 12, Article 37.3, of the Colorado Revised Statutes., and not a medical doctor or a physician licensed under Title 12, Article 36, of the Colorado Revised Statutes.

2. I recommend that the patient named below have a relationship with a licensed physician.

3.   If the patient is a child, I recommend he or she maintains a relationship with a licensed pediatric health care provider, and that the child’s parent or guardian follow the immunizations schedule that can be found at: http://www.cdc.gov/vaccines/parents/downloads/parent-ver-sch-0-6yrs.pdf

4. If the patient has a relationship with a licensed physician or pediatric health care provider, I will attempt to develop and maintain a collaborative relationship with the physician or pediatric health care provider with the permission of the patient.

_________________________________________                                     ____________

Kaycie Rosen Grigel, ND                                                                          Date

Acknowledgement and Consent for Treatment (to be completed by the adult patient, or parent/guardian if patient is a minor)

I, __________________________________________, acknowledge receipt of the above disclosure statement and give my informed consent for treatment for (circle one) myself or my child, __________________________________________ (print patient’s name) by Dr Rosen Grigel.

Check one:

The patient ___ does ___ does not have a relationship with a licensed physician or pediatric health care provider and would like Dr Grigel to contact this provider.

Name, address, phone of licensed physician or pediatric health care provider:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

I, ________________________________________(patient or guardian’s name) authorize the release of my records to the above provider from the Golden Naturopathic Clinic, LLC

____________________________________                                  _________________

Signature of Patient/Parent or Guardian                                  Date

(This form must be completed and signed prior to the initial examination of the patient.)