Welcome

Welcome to naturopathic medicine at Stonington Natural Health Center.

We are so glad that you made it here.

Here at Stonington Natural Health Center, in addition to naturopathic medicine, we offer Oriental Medicine Treatments, Massage Treatments, Garden Therapy, and Holistic Life Coaching.  These Holistic Therapies help you to heal your body.  Your body, mind, and spirit will thank you.

If you have any questions, concerns, or feedback, feel free to talk with or email us at

info@snhc.com.

We appreciate this opportunity to contribute to you on your path towards optimal health and happiness.

ALL OF US AT STONINGTON NATURAL HEALTH CENTER

The doctor of the future will give no medicine, but will interest her or his patients in the care of the human frame, in a proper diet, and in the cause and prevention of disease.

Thomas A. Edison

All life is an experiment. The more experiments you make the better.

RALPH WALDO EMERSON

Enjoy the journey.

DEEPAK CHOPRA

INFORMED CONSENT FOR NATUROPATHIC TREATMENT AND CARE

I hereby request and consent to the performance of Naturopathic Medicine treatments and other complementary medicine procedures on me (or on the patient named below, for whom I whom I am legally responsible) by Stephanie Bethune, Doctor of Naturopathic Medicine.

I understand that methods of treatment may include, but are not limited to, acupuncture, applied kinesiology, detoxification, homeopathy, hydrotherapy, Neuro-Emotional Technique, Herbal Medicine, massage, nutritional counseling, physical examination, reiki, vitamin and mineral therapy.

I will discuss with Stephanie Bethune, ND, RMT any questions or concerns that I have with my Naturopathic Medicine treatments.

The goals of Naturopathic Medicine treatments are to normalize physiological functions, to modify the perception of pain, and to treat certain diseases and dysfunctions of the body.

I have been informed that acupuncture is a safe method of treatment. Occasionally there

may be some bruising or tingling near the needling sites that lasts a few days. There have been very rare instances reported of fainting, infection and scarring. There have been extremely rare instances reported of spontaneous miscarriage and pneumothorax.

The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are considered safe in the practice of Naturopathic Medicine. I understand that some herbs may be inappropriate during pregnancy. If I experience any gastrointestinal upset or allergic reactions to the herbs, I will inform Stephanie Bethune, ND, RMT.

I do not expect the doctor to be able to anticipate and explain all risks and complications.

I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interest.

I understand my records will be kept confidential and will not be released without my written consent.

I have read, or have had read to me, the above consent. If I have any questions, I will ask. By signing below, I agree to the above named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

To be completed by the patient:

Patient’s Name: ____________________________________________

Signature ____________________________________________

Date: ____________________________________________

Are you or could you be pregnant? __________________________________________

Clinic/Office: Stonington Natural Health Center

107 Wilcox Road, Suite 103

Stonington, CT 06378

Name of Naturopathic Doctor: Stephanie Bethune, ND, RMT.

To be completed by the patient’s representative, if necessary, e.g., if the patient is a minor or is physically or legally incapacitated:

Patient’s Name: ____________________________________________

Patient’s Representative: ____________________________________________

Relationship to Authority: ____________________________________________

Witness: ____________________________________________

Stonington Natural Health Center

*acupuncture * herbal medicine * bodywork* Naturopathic care

FINANCIAL POLICIES FOR TREATMENT AND CARE

Naturopathic Medicine is excellent for helping you when you are not feeling well. If you have a cold, flu, illness or are in pain, those are the best times to come in. We prefer that you come in on time; however, if you are running late, we prefer that you arrive late rather than miss your appointment. If you need to change, reschedule, or cancel, we greatly appreciate your calling Stonington Natural Health Center as soon as you can and at least two days, or 48 HOURS, before your appointment.

“Minimum 48 Hours Cancellation Policy”:

Your appointment time is reserved for you. We prefer 48 hours notice. If LESS

THAN 24 HOURS is given to Stonington Natural Health Center for rescheduling or canceling, your credit card will be charged for the appointment. Treatment packages will have one treatment deducted.

SNHC Cancellation Policy means that if your appointment is 9am Monday, you have up to 24 hours before, or 9am Sunday, to reschedule in order not to be charged--please leave a message. We prepare our schedule days in advance, and while we know that situations arise, this policy must exist for us to be here for you. Thank you for understanding.

Payment: In an attempt to keep health care costs low, payment is required at the time of your service. Preferred payment methods are cash, check, Visa, Master Card, or Discover.

Treatment Plans: Dr. Bethune will develop your treatment plan to guide you to accomplish your goals and feel your best as soon as possible. Follow your Treatment Plan to achieve optimal results rather than experience a yo-yo effect.

Reduced Fee Treatment Packages and SNHC Massage Memberships: are available to (1) make check-out easier, (2) lower the price, and (3) make a commitment between practitioner and patient to help you complete your treatment goals. Treatment Packages and SNHC Memberships are not refundable and can only be used for the services purchased.

Treatment Packages are good for a one year time period from the date of

purchase and SNHC Massage Memberships have specific expiration dates.

Your credit card number is kept on file for payment of any missed or cancelled appointments and for guarantying personal checks. Your credit card information is kept private, confidential, and secure.

The following information is required to receive treatments:

Visa/MC ____________________________________ _______/______ _____________

(Please circle) Credit Card Number Month year 3 digit code on back

I have read, I understand, and I agree to the above information:

___________________________________ ___________________________ ___________

Signature Printed Name Date

STEPHANIE BETHUNE, ND, RMT

STONINGTON NATURAL HEALTH CENTER

107 WILCOX ROAD, SUITE 103

STONINGTON, CT 06378

PATIENT NOTICE OF PRIVACY POLICY

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Patient Rights and Uses and Disclosures of Health Information:

PERSONAL HEALTH INFORMATION DISCLOSURE:

In the course of your care as a patient at Stonington Natural Health Center, we may use or disclose personal or health related information about you in the following ways:

1. Your personal health information, including your clinical records, may be disclosed to

another health care provider or hospital if it is necessary to refer you for further

diagnosis, assessment or treatment.

2. Your health care records, as well as your billing records, may be disclosed to another

party, such as an insurance carrier, an HMO, a PPO, or your employer, if they are or

may be responsible for the payment of your services.

3. Your name and address, phone number, and your health care records may be used

to contact you regarding appointment reminders, information about alternatives to

your present care, Stonington Natural Health Center newsletters, or other health

related information that may be of interest to you. If you are not home to receive an

appointment reminder, a message may be left on your answering machine or

voicemail. Further, you have the right to refuse to provide authorization for this office

to contact you regarding these matters. If you do not provide us with this

authorization it will not affect the care provided to you, or the reimbursement

avenues associated with your care.

PERMITTED OR REQUIRED TO USE OR DISCLOSE HEALTH INFORMATION WITHOUT YOUR CONSENT OR AUTHORIZATION:

UNDER federal law, we are also permitted or required to use or disclose your

health information without your consent or authorization in these following

circumstances:

1. If we are providing health care services to you based on the orders of another health

care provider.

2. If we provide health care services to you in an emergency.

3. If there are substantial barriers to communicating with you, but in our professional

judgment believe that you intend for us to provide care.

4. If we are ordered by the courts or another appropriate agency.

ANY USE OR DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION, OTHER THAN OUTLINED ABOVE WILL ONLY BE MADE WITH YOUR WRITTEN AUTHORIZATION

We normally provide information about your health in person at the time you receive

services or care from us. We also may mail information to you regarding your health care, or about the status of your account. If you would like to receive this information at an address other than your home or, if you would like the information in a different form, please advise us in writing as to your preferences.

You have the right to inspect and/or copy your health information for seven years from

the date that the record was created or as long as the information remains in our files. In

addition, you have the right to request an amendment to your health information. Requests to inspect, copy or amend your health related information should be provided to us in writing

PRACTIONER LEGAL DUTIES

We are required by state and federal law to maintain the privacy of your patient file and

the protected health information herein. We are also required to provide you with this notice of our privacy practices with respect to your health information.

We are further required by law to abide by the terms of this notice while it is in effect.

We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice, we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all of your health information in our files.

Information we use or disclose based on this privacy notice may be subject to redisclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules.

COMPLAINTS & QUESTIONS

If you have a complaint regarding our privacy notice, our privacy practices or any aspect

of our privacy activities, you should direct your questions to: Stephanie Bethune, ND, RMT. (860) 536-3880.

This notice is effective immediately. This notice, and any alternation or amendments

made hereto, will expire seven (7) years after the date upon which the record was created. My signature acknowledges that I have received a copy of this notice.

______________________________________ ___________________________

Patient Name (printed) Signature

______________________________________

DATE

STONINGTON NATURAL HEALTH CENTER

Patient Health History

Name: _______________________________________Date: ______________

Date of Birth: _____________ Age: ______ Gender: _______________

(For insurance billing only: SS#: _____________________________)        

Street Address: ___________________________________________________

City: ____________________State: __________ Zip Code: ________________

Home Phone#: ____________   Cell Phone#:____________________________

Work Phone#:__________________Occupation:_________________________

email: _____________________________

Marital Status: __________________________

Hobbies and Interests:

________________________________________________________________

Emergency Contact: ____________Phone#: _________ Relationship: ________

Primary Care Physician:___________________           Town, State:__________

Specialist:________________Type:______________  Town, State:_________

Specialist:________________Type:_______________Town, State:_________

Specialist:________________Type:_______________Town, State:_________

How did you hear about Dr. Stephanie Bethune? ________________________________________________________________

What is your primary health concern?

________________________________________________________________

________________________________________________________________How long has this condition persisted?

________________________________________________________________

What do you think is the cause?

________________________________________________________________

________________________________________________________________

How does it affect you?

________________________________________________________________

________________________________________________________________

Have you received other treatment for this condition? Yes/No

If yes, what, when?

________________________________________________________________

Diagnosis given?

________________________________________________________________

What were the results of the treatment?

________________________________________________________________

Patient Health History

Name: _________________________________________Date: ____________

What are your hopes and expectations from treatment with Dr. Bethune?

________________________________________________________________

________________________________________________________________

Please list your most significant health problems in order of importance:

a. ______________________________________________________________ b._______________________________________________________________

c._______________________________________________________________

d._______________________________________________________________

Height _________ Weight __________ any recent weight loss or gain? Yes/No

Do you have any reason to believe you are pregnant? Yes/No

Do you have any chronic infectious diseases? Yes/No

If yes, please explain: ______________________________________________________

Are you currently suffering from any chronic illnesses? Yes/No

If yes, please explain: ______________________________________________________

Please list any hypersensitivities or allergies that you may have and your reaction:

Allergies--Foods: _____________________________________________________________

________________________________________________________________

Allergies--Medications:

_________________________________________________________

________________________________________________________________

MEDICATIONS

Please list the medication and dosages that you are currently taking. Please include both prescription and over the counter.

Medication                                                                      Dosage

1)_______________________________________________________________

2)_______________________________________________________________

3)_______________________________________________________________

4)_______________________________________________________________

5)_______________________________________________________________

SUPPLEMENTS

Please list all of the supplements that you are currently taking including dosages and brand names.

Supplement                                                Dosage                                               Brand

1)_______________________________________________________________

2)_______________________________________________________________

3)_______________________________________________________________

4)_______________________________________________________________

5)_______________________________________________________________

6)_______________________________________________________________

7)_______________________________________________________________

8)_______________________________________________________________

Please list any major surgeries that you have had and the approximate dates they occurred:

Please list any significant traumas (i.e. car accidents, bone fractures, sprains, falls, etc.):

Have you experienced any significant emotional trauma? If so, what and when?

Patient Health History

Please circle any symptoms that you currently have or have had within the past year.

General:                                      Mouth/throat and Nose:    Respiratory/Chest:

Eyes/Ears:                         Gastrointestinal:                        Cardiovascular:        

Genitourinary Tract:          Emotions:                                    Neurologic:

Female:                                  Men:                                          Skin:

Patient Health History

Musculoskeletal (pain, numbness or weakness)

Muscle spasms/cramps (where?)

________________________________________________________________

Broken bones (where?)

________________________________________________________________

Sprains/strains (where?)

________________________________________________________________

Tendonitis (where?)

___________________________________________________________

Family History:

Patient Health History

Nutrition: Please describe what you generally eat at each meal.

• Breakfast

________________________________________________________________

• Lunch

________________________________________________________________

• Dinner

________________________________________________________________

• Snacks

________________________________________________________________

Do you smoke cigarettes? Yes _____ No _____

If yes, how much? ________________________________________________________

Do you consume caffeine? Yes _____ No _____

If yes, what and how much?_________________________________________________

Do you drink soda? Yes _____ No _____

If yes, what and how much? ________________________________________________

Do you consume artificial sweeteners (nutrasweet, splenda, saccharin)?

Yes _____ No _____

If yes, how much? ________________________________________________________

Do you drink alcohol? Yes _____ No _____

If yes, how much and how often? ____________________________________________

What do you do for exercise and how often?___________________________________

________________________________________________________________

Is there anything else about you or your condition that you would like me to know or address? _______________________________________________________________

________________________________________________________________