At your initial visit, we will present a copy of the following consent for your initialing and signature:
BE WELL NATURAL MEDICINE CLINIC POLICIES AND INFORMED CONSENT
These policies are for Be Well Natural Medicine and any independent contractor who provides services at any Be Well Natural Medicine location.
We do not accept insurance or bill insurance on patients’ behalf. Payment for services is due at the time of visit. Cash, checks, Visa, Mastercard and American Express are accepted. Current rates, subject to change, are as follows:
Adult initial visit: $300
Pediatric initial visit: $250
All ages follow-up visit: Prorated at an hourly rate of $180 (30 minute minimum)
All ages follow-up visit by phone or Skype: Prorated at an hourly rate of $180 (15 minute minimum)
Acupuncture for Dr. Montgomery’s patients: $76.50
Childhood vaccination education: $150
Supplements: Cost varies by item.
Labs: Cost varies by test.
CONFIDENTIAL COLLABORATIVE CARE
Dr. Elizabeth Orchard, ND; Dr. Crystalin Montgomery ND/L.Ac and Dr. Leslie Vilensky (henceforth “the doctors”) are independent contractors who share similar philosophies and clinical training, as well as an Electronic Health Records platform. Confidential patient health records are accessible to all doctors and administrative support staff at Be Well. Additionall, hen medically necessary he doctors at Be Well may nsult with each other within the clinic egarding our care, including diagnoses, lab results, current and proposed treatments, clinical notes and any other records in your file. Your privacy is extremely important and unless required by law your records will not be released outside our clinic without explicit written permission given by you or your authorized representative.
CANCELLATION AND RETURN POLICIES
Kindly give 24 hours notice. To best serve patients who are seeking appointments, cancellations given with less than 24 hours notice will be invoiced $75.
Unopened supplements may be returned on a case by case basis, subject to approval. Please contact the front desk in advance to request a return. If approved, credit will be applied towards a future office visit or supplement charge. There is no refund on supplements.
RISKS OF USING EMAIL
Our doctors offer patients the opportunity to communicate by email. Transmitting patient information poses several risks of which the patient should be aware. The patient should not agree to communicate with the doctor via email without understanding and accepting these risks. The risks include, but are not limited to, the following:
- The privacy and security of email communication cannot be guaranteed.
- Employers and online services may have a legal right to inspect and keep emails that pass through their system.
- Email is easier to falsify than handwritten or signed hard copies. In addition, it is impossible to verify the true identity of the sender or to ensure that only the recipient can read the email once it has been sent.
- Emails can introduce viruses into a computer system and potentially damage or disrupt the computer.
- Email can be forwarded, intercepted, circulated, stored or even changed without the knowledge or permission of the doctor or the patient. Email senders can easily misaddress an email, resulting in it being sent to many unintended and unknown recipients.
- Email is indelible. Even after the sender and recipient have deleted their copies of the email, back-up copies may exist on a computer or in cyberspace.
- Use of email to discuss sensitive information can increase the risk of such information being disclosed to third parties.
- Email can be used as evidence in court.
- The doctors use gmail which does not utilize encryption software as a security mechanism for email communications. The patient waives the encryption requirement, with the full understanding that such waiver increases the risk of violation of the patient’s privacy.
CONDITIONS OF USING EMAIL
The doctors will use reasonable means to protect the security and confidentiality of email information sent and received. However, because of the risks outlined above, the doctors cannot guarantee the security and confidentiality of email communication and will not be liable for improper disclosure of confidential information that is not the direct result of intentional misconduct of the doctors. Thus, patients must consent to the use of email for patient information. Consent to the use of email includes agreement with the following conditions:
- Emails to or from the patient concerning diagnosis or treatment may be printed in full and made part of the patient’s medical record. Because they are part of the medical record, other individuals authorized to access the medical record, such as staff and billing personnel, will have access to those emails.
- As necessary, the doctors may forward emails internally to the doctors’ staff for diagnosis, treatment, reimbursement, health care operations, and other handling. The doctors will not, however, forward emails to independent third parties without the patient’s prior written consent, except as authorized or required by law.
- Although the doctors will endeavor to read and respond promptly to an email from the patient, the doctors cannot guarantee that any particular email will be read and responded to within any particular period of time. Thus, the patient should not use email for medical emergencies or other time-sensitive matters.
- Email communication is not an appropriate substitute for clinical visits, examinations, or treatment. The patient is responsible for following up on the doctor’s email and for scheduling appointments where warranted.
- If the patient’s email requires or invites a response from the doctors and the patient has not received a response within a reasonable time period it is the patient’s responsibility to follow up to determine whether the intended recipient received the email.
- The patient is responsible for informing the doctor of any types of information the patient does not want to be sent by email. Such information that the patient does not want communicated over email includes:
- The patient can add to or modify this list at any time by notifying the doctors in writing.
- The doctors are not responsible for information loss due to technical failures.
INSTRUCTIONS FOR COMMUNICATIONS BY EMAIL
To communicate by email the patient shall:
- Inform the doctors of any changes in patient’s email address.
- Withdraw consent only by email or written communication to the doctors.
- Should the patient require immediate medical assistance, the patient should not rely on email; the patient should go to Urgent Care or the Emergency Room or take other measures as appropriate.
PATIENT CONSENT AND AGREEMENT
Naturopathic medicine is founded on the belief that the body has the innate ability to heal itself. Naturopathic doctors combine the wisdom of nature with the rigors of modern science. Naturopathic doctors look at more than symptoms; we seek to identify the underlying cause of the symptoms. Naturopathic doctors assess the whole person and consider the physical, mental and emotional expression of wellness and disease. Gentle, non-invasive techniques are often used to stimulate the body’s ability to heal itself. Following are some of the approaches that may be used: physical examination and diagnostic assessment; ordering and interpreting labs; nutrition, diet and lifestyle counseling; botanical medicine; homeopathy; high quality supplement recommendations and naturopathic physical manipulation. Therapies recommended by the doctors may not be FDA-approved.
I hereby request and consent to services rendered and treatment provided by Dr. Elizabeth Orchard, ND; Dr. Crystalin Montgomery, ND/L.Ac. and Dr. Leslie Vilensky, ND. I recognize that the above mentioned doctors are board certified Naturopathic Doctors registered by the Minnesota Board of Medical Practice and that their services are not meant to replace or be a substitute for those of a medical doctor. I understand that the doctors advise that I seek concurrent care of a primary care physician licensed in Minnesota. I have the right to refuse any treatment suggested that I am uncomfortable with. The above mentioned doctors have the right to treat me within the scope of their practice and the right to refuse treatment or make referrals to outside practitioners if they feel that they may be of service to my case.
After reading each item below, please initial in the space provided. If you have any questions or concerns about the item please express it to the office manager or doctor before initialing.
_____ I understand that even the gentlest of therapies can cause complications or side effects. As in conventional medicine, the practice of naturopathic medicine carries risks of treatment, which may include but not be limited to: allergic reaction to supplements or botanical medicines, aggravation of preexisting symptoms and risk of pharmaceutical/supplement interaction. To reduce these risks, I agree that it is my responsibility to inform the doctors of any diseases or allergies I have, as well as any medications or supplements that I am currently taking.
_____ I agree to inform the doctors if I have a bleeding disorder, pace maker, and/or cancer.
_____ (Females only): I agree to alert the doctors if I have a suspected or confirmed pregnancy, since some of the the recommended therapies could present a risk to the pregnancy.
_____ I do not expect the doctors to be able to anticipate and explain all risks and complications. I wish to rely on the doctors to exercise their judgment in my best interest, based upon the facts then known. I understand that results are not guaranteed.
_____ I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others without my expressed written consent or if required by law. I understand that I may look at my medical record at any time and may request a copy. I understand that information from my record may be analyzed for research purposes and that my identity will be protected and kept confidential.
I acknowledge that I have read and fully understand this consent form. I have also had an opportunity to ask questions about its content. 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 from the doctors at Be Well Natural Medicine.
Name (please print)
Signature (or Guardian if a minor) and date
TRADITIONAL CHINESE MEDICINE AND ACUPUNCTURE INFORMED CONSENT
The purpose of this form is to present the risks & benefits of additional services offered by Crystalin Montgomery, ND, L.Ac.
By signing below, I do hereby voluntarily consent to be treated with acupuncture and/or substances from the Oriental Materia Medica by a licensed acupuncturist at the Chinese Medical Clinic. I understand that acupuncturists practicing in the state of Minnesota are not primary care providers and that regular primary care by a licensed physician is an important choice that is strongly recommended by this clinic’s practitioners.
I understand that acupuncture is performed by the insertion of needles through the skin or by the application of heat to the skin (or both) at certain points on or near the surface of the body in an attempt to treat bodily dysfunction or diseases, to modify or prevent pain perception, and to normalize the body’s physiological functions. I am aware that certain adverse side effects may result. These could include, but are not limited to: local bruising, mπinor bleeding, fainting, pain or discomfort, and the possible aggravation of symptoms existing prior to acupuncture treatment. I understand that no guarantees concerning its use and effects are given to me and that I am free to stop acupuncture treatment at any time.
I understand that if I receive direct moxibustion as part of therapy, there is a risk of burning or scarring from its use. I understand that I may refuse this therapy.
I understand that substances from the Oriental Materia Medica may be recommended to me to treat bodily dysfunction or diseases, to modify or prevent pain perception, and to normalize the body’s physiological functions. I understand that I am not required to take these substances but must follow the directions for administration and dosage if I do decide to take them. I am aware that certain adverse side effect may result from taking these substances. These could include, but are not limited to: changes in bowel movement, abdominal pain or discomfort, and the possible aggravation of symptoms existing prior to herbal treatment. Should I experience any problems, which I associate with these substances, I should suspend taking them and call the Chinese Medical Clinic as soon as possible.
I understand that I may also be given acupressure/tui-na massage as part of my treatment to modify or prevent pain perception and to normalize the body’s physiological functions. I am aware that certain adverse side effects may result from this treatment. These could include, but are not limited to: bruising, sore muscles or aches, and the possible aggravation of symptoms existing prior to treatment. I understand that I may stop the treatment if it is too uncomfortable.
I understand that I may be asked to have electro-acupuncture administered with the acupuncture. I am aware that certain adverse side effects may result. These may include, but are not limited to: electrical shock, pain or discomfort, and the possible aggravation of symptoms existing prior to treatment. I understand that I may refuse this treatment.
Please inform Dr. Montgomery of any changes in symptoms, medications, diagnoses by other doctors and if there is a chance of pregnancy at any time during your care.
I have read and understand the information provided. I agree to the services provided by Crystalin Montgomery, ND, L.Ac. I understand that Crystalin Montgomery, ND, LAc is an independent contractor at Be Well Natural Medicine. Be Well Natural Medicine is not responsible for services provided by Crystalin Montgomery, ND, LAc.
Name (please print)
Signature (or Guardian if a minor) Date
BE WELL NATURAL MEDICINE CANCELLATION POLICY
Our cancellation policy allows us to provide the best service to all of our patients and use our clinic’s resources optimally.
While we appreciate 48 hours notice if you need to reschedule or cancel your appointment - you can use the link provided in your appointment confirmation email to easily modify an existing appointment up to 24 hours before your scheduled time.
We understand unforeseeable emergencies do occur, so if an appointment is missed or broken with less than 24 hours notice or no notice is given, a note will be placed in your account.
However, on the second missed appointment - you will be invoiced according to the fees below, and your ability to schedule future appointments will be suspended until your account is paid in full. All subsequent missed appointments even after fees have been paid will immediately result in an invoice being sent and a suspended account.
- Acupuncture: $40
- All other appointments: $75
By signing below, I indicate that I have read and understood this policy.
Name (please print)
Signature (or Guardian if a minor) Date