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New Patient and Telemedicine Consent

Please downoload consent agreement. Fill it out and send it back to us using this contact form
Consent Form PDF FIle

New Patient and Telemedicine Consent

The NES team welcome’s you on an exciting journey of health. Our philosophy is rooted in the principles of naturopathic medicine, which are:
  1. The Healing Power of Nature (Vis Medicatrix Naturae)
  2. Identify and Treat the Causes (Tolle Causam)
  3. First Do No Harm (Primum Non Nocere)
  4. Doctor as Teacher (Docere)
  5. Treat the Whole Person
  6. Prevention
  7. Wellness
We help our patients feel great, discover the root causes of disease and help find treatment plans that are destined toward optimal being. We take a comprehensive approach and research solutions that help you achieve your health goals. We are your natural partner in this journey. We would love to communicate on how we can best work together and have outlined some key information below to help us better serve you. We want to know more about you and want to take the time to get it right. What to Expect as a New Patient At NES, when you establish a new physician patient relationship, we require that you fully review the new patient forms in detail and ask as many questions you may have.

Please carefully read the following information. If you agree, please sign and date the consent form at the end of this document.

Confidentiality All information that you provide is strictly confidential. If you are requesting a copy of your medical records to be released to anyone or if you are requesting a copy of your records to be sent to NES, you need to fill out a Records Release Form. Scheduling and Missed/Cancelled Appointments At NES, we will send out a 72-hour appointment reminder. It is the patient’s responsibility to keep track of the appointment date and time and to arrive in a timely manner. In order to provide all patients with high quality care, we require a 48-hour cancellation notice. This reserved time has been allotted to you and if you need to change it, we would appreciate the notice so that we can better serve you and our patients receiving care. Patients arriving more than 10 minutes late to their appointment will be subject to the providers’ decision to be seen, rescheduled or changed to a brief visit. Patients arriving more than 20 minutes late will be subject to a rescheduled appointment. Patients who do not call or show up for the scheduled appointment will be subject to a missed appointment fee of 100% of visit. Anytime there is a no call/no show or missed appointment, this will be documented in your chart. Numerous missed appointments can result in dismissal from the practice and/or require you to prepay for your visit. We understand that emergencies do occur and you may not be able to communicate your absence for a scheduled appointment. We will remind you about this policy after the first occurrence. After the second and future occurrences, you will be charged the appointment cost. Financial Agreement At NES, you will have a couple of payment options. You can either prepay for the visit online or by calling the office or pay at the time of service. Please keep in mind that this is a cash pay practice and we are not associated with any insurance companies. We can assist you with reimbursement documents that you can submit to your insurance if needed. We cannot bill directly to any insurance company and it is your responsibility to check with your insurance provider to see if you are eligible for coverage and/or reimbursements for any visits and services you receive. If you cannot pay for the visit at the end of service, you will be sent a bill within 7 days. If you do not pay your bill within 30 days of receiving it, it will be sent to the Professional Credit Services (Collection agency) and you will be responsible for any fees incurred. Patient Services and Treatments At NES, we provide a range of services such as telephone consultations, telemedicine (such as videoconferencing) consultations, and in person visits. We can recommend different types of therapies to assist in your healthcare treatment plan. Some of these therapies may or may not be FDA approved. Examples of treatments include and are not limited to:
  • IV therapy
  • IM therapy
  • Hormone Therapy, including pellet therapy
  • Medications
  • Supplements
  • Specialty Lab recommendations
  • Acupuncture
Telemedicine Waiver I hereby consent to engaging in telemedicine with NES (Natural Endocrinology Specialists). “Telemedicine” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand that telemedicine involves the communication of my medical information on an interactive platform where I can see and hear my provider. The confidentiality laws that apply in person visits also apply in a telemedicine appointment. As such, I understand the disclosed information is HIPAA regulated (Health Insurance Portability and Accountability Act). By signing this consent, I agree and would like to engage in a telemedicine visit. I recognize that this does not replace an in person visit and this is a platform that is being offered to help provide options in my care. I understand that if I have a medical emergency, I have to call 911 (Emergency Care) and that telemedicine service does not cover this. I understand that telemedicine appointments both have advantages and disadvantages. Advantages include convenience and accessibility to getting a doctor's appointment. Disadvantages include the visits not being as complete as a face-to-face service, internet and technology issues. If my provider feels that an in-person visit would be more advantageous for my health care plan, I understand that I can be asked to schedule this visit. In any medical treatments, there are potential risks and benefits despite the efforts of the provider. I understand that my condition may not be improved and/or my provider may suggest and refer me out for additional care. I understand that results cannot be guaranteed. Communication It is the patient’s responsibility to notify their provider regarding any changes in medical history. The patient shall communicate with the provider of any change in their medical history such as (but not limited to) medications, supplements, allergies and new diagnosis. The patient can communicate with our staff and providers via the patient portal, email, fax, phone number, text messaging and telemedicine appointments. We aim to respond to messages sent via the patient portal within 48 hours during the workweek and 72 hours on weekends. For phone consultations, these must be scheduled as an appointment, with a fee applied for the allocated time. In the time between appointments, we offer the convenience of sending up to two messages in your patient portal to address any questions, seek clarification, or discuss concerns related to your treatment plan. Please be aware that after these two messages, each subsequent message will incur a fee of $25. Outcomes and Results and Referrals At NES, we aim highly to help our patients achieve optimal health. Results are not guaranteed and can vary from patient to patient. These outcomes also depend on patient compliance with the treatment plan recommendations provided by your doctor. We work collaboratively with other specialist physicians and can be referred for additional care if the area of concern is beyond the scope of naturopathic medicine. Principle of Do No Harm I understand that the doctor will have to use his/her judgment, clinical experience, skills and training to make the best medical decision in treatment, even if that treatment will include using medications, procedures, injections, prescriptions, supplements that may have some side effects which the doctor did not anticipate and that the doctor made the best choice with all the facts at hand at the time of the decision. Potential Side effects from treatments or therapies used: In medicine, there can be unforeseeable circumstances in which a patient may have an allergic reaction(s) or side effect(s) from treatment that involves (but is not limited to) supplements, medications, IV therapy ingredients, IM therapy ingredients, and more. Examples of side effects include:
  • Syncope (fainting, vasovagal reactions, dizziness, lightheaded, weakness) when getting procedures such as IV, IM or lab draws and other therapies such as acupuncture.
  • Scars (from hormone pellet therapy, acupuncture treatment, IM shots) and others
  • Adverse reactions to hormone therapy such as:
    • Skin & Body changes: acne, hair growth on face/body, voice changes, body changes (with hormone therapy)
    • Hair loss
    • Increased breast size
    • Increased breast tenderness
    • Vaginal bleeding (from hormone therapy treatments using Estradiol, progesterone, DHEA and testosterone)
    • Increase/ changes in breast tissue density
    • Increased red blood cell formation, hemoglobin and hematocrit
    • Decreased sperm count (with testosterone therapy)
    • Decreased testicle size
    • Fluid retention
    • Mood changes (ex. more aggressive)
  • Organ puncture (acupuncture, IV therapy, IM therapy, hormone treatment)
  • Organ failure
Patient responsibility As a patient at NES, I am consenting to accepting patient responsibility for following through on:
  • Lab work recommendations from the doctor
  • Treatment recommendations from the doctor
  • Staying up to date with screenings/imaging recommendations from the doctor such as:
    • Thyroid imaging (Ultrasounds, biopsy, etc)
    • Mammograms
    • Colonoscopy
    • PSA testing, DRE exams (with primary care doctor)
    • PAP smears
    • Pelvic/transvaginal ultrasounds
  • Communicating to NES about any changes in my treatment plan
  • Communicating to NES about any side effects from treatment plan
I have read the above information and consent with permission to establish care with NES. I understand that I may ask as many questions before signing this consent form. I voluntarily consent to all of the above and understand that results are not guaranteed regarding my health outcomes. I am aware and consent to be financially responsible for all services rendered. I certify the information provided to NES is accurate to the best of my ability. I understand that omitting medical information to the provider may result in an inaccurate diagnosis and treatment.

New Patient and Telemedicine Consent

The NES team welcome’s you on an exciting journey of health. Our philosophy is rooted in the principles of naturopathic medicine, which are:

  1. The Healing Power of Nature (Vis Medicatrix Naturae)
  2. Identify and Treat the Causes (Tolle Causam)
  3. First Do No Harm (Primum Non Nocere)
  4. Doctor as Teacher (Docere)
  5. Treat the Whole Person
  6. Prevention
  7. Wellness

We help our patients feel great, discover the root causes of disease and help find treatment plans that are destined toward optimal being. We take a comprehensive approach and research solutions that help you achieve your health goals. We are your natural partner in this journey.

We would love to communicate on how we can best work together and have outlined some key information below to help us better serve you. We want to know more about you and want to take the time to get it right.

What to Expect as a New Patient
At NES, when you establish a new physician patient relationship, we require that you fully review the new patient forms in detail and ask as many questions you may have.

Please carefully read the following information.
If you agree, please sign and date the consent form at the end of this document.

Confidentiality
All information that you provide is strictly confidential. If you are requesting a copy of your medical records to be released to anyone or if you are requesting a copy of your records to be sent to NES, you need to fill out a Records Release Form. Scheduling and Missed/Cancelled Appointments
At NES, we will send out a 72-hour appointment reminder. It is the patient’s responsibility to keep track of the appointment date and time and to arrive in a timely manner. In order to provide all patients with high quality care, we require a 48-hour cancellation notice. This reserved time has been allotted to you and if you need to change it, we would appreciate the notice so that we can better serve you and our patients receiving care. Patients arriving more than 10 minutes late to their appointment will be subject to the providers’ decision to be seen, rescheduled or changed to a brief visit. Patients arriving more than 20 minutes late will be subject to a rescheduled appointment. Patients who do not call or show up for the scheduled appointment will be subject to a missed appointment fee of 100% of visit. Anytime there is a no call/no show or missed appointment, this will be documented in your chart. Numerous missed appointments can result in dismissal from the practice and/or require you to prepay for your visit. We understand that emergencies do occur and you may not be able to communicate your absence for a scheduled appointment. We will remind you about this policy after the first occurrence. After the second and future occurrences, you will be charged the appointment cost.

Financial Agreement
At NES, you will have a couple of payment options. You can either prepay for the visit online or by calling the office or pay at the time of service. Please keep in mind that this is a cash pay practice and we are not associated with any insurance companies. We can assist you with reimbursement documents that you can submit to your insurance if needed. We cannot bill directly to any insurance company and it is your responsibility to check with your insurance provider to see if you are eligible for coverage and/or reimbursements for any visits and services you receive. If you cannot pay for the visit at the end of service, you will be sent a bill within 7 days. If you do not pay your bill within 30 days of receiving it, it will be sent to the Professional Credit Services (Collection agency) and you will be responsible for any fees incurred.

Patient Services and Treatments
At NES, we provide a range of services such as telephone consultations, telemedicine (such as videoconferencing) consultations, and in person visits. We can recommend different types of therapies to assist in your healthcare treatment plan. Some of these therapies may or may not be FDA approved. Examples of treatments include and are not limited to:

  • IV therapy
  • IM therapy
  • Hormone Therapy, including pellet therapy
  • Medications
  • Supplements
  • Specialty Lab recommendations
  • Acupuncture

Telemedicine Waiver
I hereby consent to engaging in telemedicine with NES (Natural Endocrinology Specialists). “Telemedicine” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand that telemedicine involves the communication of my medical information on an interactive platform where I can see and hear my provider. The confidentiality laws that apply in person visits also apply in a telemedicine appointment. As such, I understand the disclosed information is HIPAA regulated (Health Insurance Portability and Accountability Act).

By signing this consent, I agree and would like to engage in a telemedicine visit. I recognize that this does not replace an in person visit and this is a platform that is being offered to help provide options in my care. I understand that if I have a medical emergency, I have to call 911 (Emergency Care) and that telemedicine service does not cover this. I understand that telemedicine appointments both have advantages and disadvantages. Advantages include convenience and accessibility to getting a doctor's appointment. Disadvantages include the visits not being as complete as a face-to-face service, internet and technology issues. If my provider feels that an in-person visit would be more advantageous for my health care plan, I understand that I can be asked to schedule this visit.

In any medical treatments, there are potential risks and benefits despite the efforts of the provider. I understand that my condition may not be improved and/or my provider may suggest and refer me out for additional care. I understand that results cannot be guaranteed.

Communication

It is the patient’s responsibility to notify their provider regarding any changes in medical history. The patient shall communicate with the provider of any change in their medical history such as (but not limited to) medications, supplements, allergies and new diagnosis. The patient can communicate with our staff and providers via the patient portal, email, fax, phone number, text messaging and telemedicine appointments.

We aim to respond to messages sent via the patient portal within 48 hours during the workweek and 72 hours on weekends. For phone consultations, these must be scheduled as an appointment, with a fee applied for the allocated time.

In the time between appointments, we offer the convenience of sending up to two messages in your patient portal to address any questions, seek clarification, or discuss concerns related to your treatment plan. Please be aware that after these two messages, each subsequent message will incur a fee of $25.

Outcomes and Results and Referrals At NES, we aim highly to help our patients achieve optimal health. Results are not guaranteed and can vary from patient to patient. These outcomes also depend on patient compliance with the treatment plan recommendations provided by your doctor. We work collaboratively with other specialist physicians and can be referred for additional care if the area of concern is beyond the scope of naturopathic medicine.

Principle of Do No Harm
I understand that the doctor will have to use his/her judgment, clinical experience, skills and training to make the best medical decision in treatment, even if that treatment will include using medications, procedures, injections, prescriptions, supplements that may have some side effects which the doctor did not anticipate and that the doctor made the best choice with all the facts at hand at the time of the decision.

Potential Side effects from treatments or therapies used: In medicine, there can be unforeseeable circumstances in which a patient may have an allergic reaction(s) or side effect(s) from treatment that involves (but is not limited to) supplements, medications, IV therapy ingredients, IM therapy ingredients, and more. Examples of side effects include:
  • Syncope (fainting, vasovagal reactions, dizziness, lightheaded, weakness) when getting procedures such as IV, IM or lab draws and other therapies such as acupuncture.
  • Scars (from hormone pellet therapy, acupuncture treatment, IM shots) and others
  • Adverse reactions to hormone therapy such as:
    • Skin & Body changes: acne, hair growth on face/body, voice changes, body changes (with hormone therapy)
    • Hair loss
    • Increased breast size
    • Increased breast tenderness
    • Vaginal bleeding (from hormone therapy treatments using Estradiol, progesterone, DHEA and testosterone)
    • Increase/ changes in breast tissue density
    • Increased red blood cell formation, hemoglobin and hematocrit
    • Decreased sperm count (with testosterone therapy)
    • Decreased testicle size
    • Fluid retention
    • Mood changes (ex. more aggressive)
  • Organ puncture (acupuncture, IV therapy, IM therapy, hormone treatment)
  • Organ failure

Patient responsibility As a patient at NES, I am consenting to accepting patient responsibility for following through on:

  • Lab work recommendations from the doctor
  • Treatment recommendations from the doctor
  • Staying up to date with screenings/imaging recommendations from the doctor such as:
    • Thyroid imaging (Ultrasounds, biopsy, etc)
    • Mammograms
    • Colonoscopy
    • PSA testing, DRE exams (with primary care doctor)
    • PAP smears
    • Pelvic/transvaginal ultrasounds
  • Communicating to NES about any changes in my treatment plan
  • Communicating to NES about any side effects from treatment plan

I have read the above information and consent with permission to establish care with NES. I understand that I may ask as many questions before signing this consent form. I voluntarily consent to all of the above and understand that results are not guaranteed regarding my health outcomes. I am aware and consent to be financially responsible for all services rendered.

I certify the information provided to NES is accurate to the best of my ability. I understand that omitting medical information to the provider may result in an inaccurate diagnosis and treatment.

7500 E. Pinnacle Peak Rd.
Suite A 109
Scottsdale, AZ 85255
Phone: 480-687-0054
FAX: 833-605-1101
Mon: 8:30AM - 4:30PM
Tue: 8:30AM - 4:30PM
Wed: 7:30AM - 4:30PM
Thu: 8:30AM - 4:30PM
Fri: 8:30AM - 3:30PM
Sat - Sun: Closed
Dr. Linda Khoshaba is the Leading Integrative Health and Hormone Doctor in Scottsdale, Arizona. She has extensive experience working in the field as a Hormone Specialist and Natural Endocrinologist.

7500 E. Pinnacle Peak Rd. Suite A 109
Scottsdale, AZ 85255

Mon: 8:30AM - 4:30PM
Tue: 8:30AM - 4:30PM
Wed: 7:30AM - 4:30PM
Thu: 8:30AM - 4:30PM
Fri: 8:30AM - 3:30PM
Sat - Sun: Closed
This Site may include a variety of features, such as health tips and videos, services provided at Natural Endocrinology Specialists™, our online Supplement store, NESAZ Programs, email, and patient portal services. DISCLAIMER: These statements have not been evaluated by the Food & Drug Administration. These programs and products are not intended to diagnose, treat, cure, or prevent any disease. The information contained herein is for informational purposes. Please be sure to consult your doctor before taking this or any other product/program. Consult your doctor for any health problems or before starting a new program.
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