New Naturopathic and Functional Medicine Client Registration

Welcome! I am honored to be a part of your journey to optimal health and respect the courageous path you have chosen to address life with thoughtfulness and care.

To ensure that we begin our relationship with a clear understanding so that you are empowering yourself to receive the best possible service while minimizing any confusion or concerns down the road, we want you to be fully informed about our services and policies and request that you read, understand and sign the below documents prior to beginning our work together.

New Naturopathic and Functional Medicine Patient Checklist

• Read and sign the following documents acknowledging that you have read, understand and agree to them.
• Important Patient Information
• Informed Consent to Naturopathic and Functional Medicine Evaluation and Treatment
• Informed Consent to Telehealth Services
• Informed Consent for Functional Lab Testing
• Informed Consent Regarding Use of Protected Health Information
• Notice of Privacy Practices & Acknowledgment of Receipt of Notice of Privacy Practices
• Financial and Cancellation Policies
• Health History Intake

Thank you and I look forward to working with you!
~ Dr. Pedi Mirdamadi, ND, MSc, RHN

IMPORTANT PATIENT INFORMATION

NATUROPATHIC AND FUNCTIONAL MEDICINE

WHAT TO EXPECT AT YOUR NATUROPATHIC AND FUNCTIONAL MEDICINE SESSIONS
Please be sure to be available at your expected appointment time. At the first appointment, together we will review the results of your initial intake and explore all aspects of life that affect your health and well-being. We will then develop and review whole-person approach to your health.

PAYMENT 
Payment is due in full prior to time of service. We bill via Stripe and accept MasterCard, Visa, Discover and American Express credit cards.

NO INSURANCE FOR PATIENTS LOCATED IN THE UNITED STATES
Dr. Pedi Natural Health does not accept or bill insurance or Medicare for patients located in the United States. Dr. Mirdamadi is not a Medicare provider and therefore is unable to submit claims. However, upon request, we can provide you with a superbill so that you may submit to your carrier for potential reimbursement at an out-of-network rate after you have met your deductible. This does not guarantee reimbursement, so we recommend calling your insurance carrier beforehand to find out what will or will not be reimbursed.

CANCELLATION POLICY
Due to Dr. Mirdamadi’s extensive preparation prior to your appointments, we require 48-hours’ notice prior to any cancellations or changes of your scheduled appointment. Cancellations made at least 48 hours in advance allow Dr. Mirdamadi to accommodate others and to provide the best care possible. Please read our full Financial and Cancellation Policies and note that for any cancellation within 48 hours of your scheduled appointment you will be charged 100% of the amount of your scheduled appointment. We thank you in advance for your cooperation.

LATE ARRIVAL POLICY 
Dr. Mirdamadi is committed to being on time with patients’ appointments in order to prevent patients from waiting. If you arrive late to your appointment, your appointment will end at the scheduled time and you will be charged for the full length of the originally scheduled appointment.

LAB TESTS
Please be aware that while Dr. Mirdamadi may order lab tests for you, he is only doing so on your behalf. Fees for naturopathic and functional medicine services do not cover lab testing, and fees for such tests are billed directly by the lab to you.  Dr. Mirdamadi uses certain labs that insurance may cover, depending on individual plans, but it is the patient’s responsibility to understand their insurance coverage, including coverage of lab testing fees. Dr. Mirdamadi and Dr. Pedi Natural Health is not responsible for any billing related to insurance claims.  What you might owe for lab tests and what is covered by insurance varies widely from network to network. To prevent the stress of unexpected bills we urge you to contact your insurance company so you can have a good understanding of your lab benefits prior to completing any lab tests. 

MATERIAL CONNECTION DISCLOSURE 
Dr. Mirdamadi may occasionally make recommendations for goods for which he has a material connection and may be compensated if and when you purchase such goods. Though the advice is in good faith and Dr. Mirdamadi only recommend the highest quality products and services from vendors and practitioners that Dr. Mirdamadi knows and trusts, you should always perform due diligence before buying goods or services from anyone online or offline.

ONLINE DISPENSARY 
All prescriptions and recommendations for dietary supplements will be shared via a HIPPA compliant Online Dispensary Platform which may be Wellevate and/or Fullscript. I understand that I will receive an invitation from Dr. Pedi Natural Health and will need to set up a free account with Wellevate or Fullscript as applicable to access my recommendations. This prevents recommendations or identifiable health information from being shared from practitioner to patient via email, and serves as a place for patients to access prior recommendations in the future. Recommendations for dietary supplements will also be made through Wellevate and/or Fullscript. I understand that if I purchase the recommended products through Wellevate or Fullscript, Dr. Pedi Natural Health earns a small percentage of that sale. I understand that all recommendations are made in good faith, and for the patients’ needs. I understand that I am under no obligation to purchase the recommended products from Wellevate or Fullscript or from Dr. Pedi Natural Health, and that should I choose to not purchase the recommended products, or to purchase them elsewhere, the nature of our consultative relationship will not change. Finally, I understand that the revenue from purchasing supplements goes to support Dr. Pedi Natural Health’s small business, and that any income earned assists in preserving longer patient visit times and keeping costs stable.

I truly look forward to working with you as part of your health care team!
~Dr. Pedi Mirdamadi, ND, MSc, RHN

 

Informed Consent to
Naturopathic and Functional Medicine Evaluation and Treatment

This Informed Consent to Naturopathic and Functional Medicine Evaluation and Treatment provides important information regarding the services being provided and should be carefully reviewed before beginning your work with Dr. Pedi Mirdamadi, ND. It is designed to inform you about Dr. Mirdamadi’s practices, to ensure that you understand the professional relationship between doctor and patient, and to obtain your informed consent in this relationship. Your informed consent is important not only because it protects both parties in this relationship, but also because it helps you to feel empowered in your own healing process, which in turn encourages healing at all levels of your being. When you sign this document, it will authorize Dr. Mirdamadi to initiate care and commence treatment in accordance with this document. Please ask any questions you have regarding this document and Dr. Mirdamadi’s services before signing this document.
 
By signing below, I acknowledge and agree to the following:

I hereby request and consent to receive naturopathic medical care, treatment, procedures and/or other naturopathic and functional medicine services (“Naturopathic Medical Treatments”), as more fully outlined below, by Dr. Pedi Mirdamadi, ND, MSc, RHN (“Dr. Mirdamadi”) dba Dr. Pedi Natural Health.
I acknowledge that Dr. Mirdamadi is a licensed naturopathic doctor in the state of California (License number ND1106. I understand that Dr. Mirdamadi may only provide naturopathic medical care to me via telehealth or otherwise when I am located in California.

I hereby authorize Dr. Mirdamadi to provide the following Naturopathic Medicine Treatments as permitted by the State of California and as necessary to facilitate my diagnosis and treatment:

• Medicinal use of nutrition: The use of therapeutic nutrition, nutritional supplementation (with vitamins, minerals, and amino acids), and intravenous and intramuscular vitamin infusions and injections.
• Botanical medicine: The use of botanical substances as teas, tinctures, capsules, tablets, creams or suppositories.
• Homeopathic medicine: The use of highly dilute quantities of naturally occurring plants, animals, and minerals to gently stimulate the body’s healing response.
• Lifestyle counseling: Recommendations with respect to diet, exercise, sleep, stress reduction and balancing of work and social activities.
• Prescription Medications: Prescriptions for pharmaceutical medications including bioidentical hormone replacement therapy.
• Telehealth*: Diagnosis, consultation, treatment, education, care management and self-care management via information and communication technologies.

*Telehealth Services provided only after signing the Informed Consent to Telehealth Services.
I have had the opportunity to discuss with Dr. Mirdamadi the nature and purpose of the Naturopathic Medicine Treatments. I understand that all Naturopathic Medicine Treatments will be discussed with me before treatment begins and I am encouraged to ask questions.

Potential Benefits of Naturopathic Medical Treatments: I understand that potential benefits of Naturopathic Medical Treatments include, but are not limited to: restoration of health and the body’s maximal functional capacity; relief of pain and symptoms of disease; assistance in injury and disease recovery; and prevention of disease or its progression.

Potential Risks of Naturopathic Medical Treatments:
I am aware that all existing methods of diagnosis and treatment, including naturopathic medical care, pose some level of risk. Within the general healthcare setting, the possible outcomes of these practices by a naturopathic doctor range from minor to fatal. I understand that potential risks of Naturopathic Medical Treatments include, but are not limited to: allergic reactions to prescribed supplements, medications, and herbs, which may be severe such as anaphylaxis, cardiac arrest and death; unpleasant side effects from and between natural medications and pharmaceuticals; inconvenience of lifestyle changes; aggravation of present conditions; injuries such as pain, discomfort, discoloration, and pneumothorax from injections (vitamin injections, trigger point injections, Prolotherapy/PRP, and stem cell growth factor injections), venipuncture and other procedures; and soft tissue or bony injury from physical manipulation and other procedures. There may also be other potential risks of the Naturopathic Medical Treatments which may also be discussed and clarified in separate consents specifically applicable to such treatments such as intravenous and injection therapy.
I am aware that unforeseeable complications could occur, and that while Dr. Mirdamadi will make every reasonable effort during the examination to screen for contraindications to care, I do not expect Dr. Mirdamadi to be able to anticipate and explain all possible risks and complications, and I wish to rely on Dr. Mirdamadi to exercise judgment in recommending the Naturopathic Medical Treatments that he feels at the time, based on the facts then known, are in my best interest.

I understand that in order to properly treat my medical condition, Dr. Mirdamadi must be contacted promptly if an adverse reaction or condition occurs. I agree that I will immediately inform Dr. Mirdamadi if I experience any gastrointestinal upset (e.g., nausea, gas, stomachache, vomiting or similar condition), allergic reactions (e.g., hives, rashes, tingling of the tongue, headache or similar condition), or any unanticipated or unpleasant effects associated with any of the Naturopathic Medical Treatments prescribed by Dr. Mirdamadi.
In any event, if an emergency medical condition arises for any reason due to a Naturopathic Medical Treatment from Dr. Mirdamadi or for any other reason, I agree to seek treatment immediately from an emergency center or call 9-1-1.

Following Doctor Instructions: I understand that the Naturopathic Medical Treatments including herbs, homeopathic medicines and nutritional supplements (which are from plant, animal, mineral and other sources), prescriptions and other treatments that may be recommended by Dr. Mirdamadi, are considered safe when taken as instructed in the practice of naturopathic medicine. I am aware that it is extremely important that I follow the Dr. Mirdamadi prescribed recommendations when taking any prescriptions, herbs, homeopathic medicines and nutritional supplements because they may be toxic when taken in large doses. I understand that following all instructions, whether orally and/or in writing, helps to improve the safety and outcomes of treatment.

Complete Medical History:
I understand that some herbs, medications, supplements, diets, or treatments may be inappropriate if I have certain health conditions or take certain medications or supplements, whether prescribed or over-the-counter, and I agree that I will notify Dr. Mirdamadi of all of my pre-existing health conditions, medications and supplements as well as keep Dr. Mirdamadi updated as to any changes.
I have truthfully and accurately disclosed to Dr. Mirdamadi all personal medical history information including but not limited to:

• all of my health conditions,
• my use of all medications, drugs, herbs, vitamins, and other supplements of any kind; and
• all known allergies to drugs or other substances or any past reactions.

I understand that failure to do so may negatively affect my treatment outcome and the safety of any treatments I receive. I agree to keep Dr. Mirdamadi updated as to any changes in my medical profile and understand that there shall be no liability on Dr. Mirdamadi’s part should I fail to do so.

Notice to All Female Patients: I understand that some treatments, including without limitation, herbs and supplements, could present a risk during pregnancy and breastfeeding, and I agree that I will notify Dr. Mirdamadi immediately if I am pregnant, if I become pregnant, if I am planning to become pregnant in the next three (3) months or if I am breastfeeding.

Notice to All Patients Receiving Bio-Identical Hormone Therapy:
I understand that it is Dr. Mirdamadi’s policy that all female patients must see a gynecologist for a gynecological pelvic exam including PAP smear as well as have breast imaging within three months prior to starting hormone therapy and must agree to continue to have gynecological pelvic and breast exams, as well as breast imaging, annually thereafter during the course of hormone therapy, and all male patients must have a Digital Rectal Exam and PSA test within the three months prior to starting hormone therapy and must agree to have a Digital Rectal Exam and PSA test annually thereafter during the course of hormone therapy.
I understand that all patients being placed on bioidentical hormone replacement agree to follow-up appointments with Dr. Mirdamadi as well as blood work every 3-6 months and a 24-hour urine hormone monitoring test annually during the course of hormone therapy.

Notice to All Cancer Patients:
I acknowledge and understand that Dr. Mirdamadi does not treat cancer, but that the treatments and procedures provided by Dr. Mirdamadi may help to optimize the immune system to be able to respond better to cancer. Therefore, if I have cancer, or suspect I have cancer, I understand that I am required to be under the ongoing care of a board-certified oncologist or other MD or DO with experience working with malignant conditions, and I agree that my relationship with this MD or DO shall be the primary therapeutic relationship and that the care I receive from Dr. Mirdamadi shall be secondary and supportive of my general health and shall not be understood as treatment of a malignancy.

Relationship with Other Healthcare Providers:
Naturopathic Medicine may be a complement to traditional allopathic medicine. I acknowledge that I have been informed and I understand that:

• Any treatment or advice provided to me by Dr. Mirdamadi as a patient is not mutually exclusive from any treatment or advice that I may now be receiving, or may in the future receive, from any other licensed health care provider.
• I am at liberty to seek or continue medical care from a physician or surgeon or other qualified health care provider.
• Neither Dr. Mirdamadi nor any employee or other practitioner under Dr. Mirdamadi’s direction or control is suggesting or advising me to refrain from seeking or following the directions of another licensed health care provider.
• The treatment and therapies rendered or recommended by Dr. Mirdamadi may be different than those usually offered by a medical doctor or other licensed health care provider.

 I also understand that it is my responsibility on an ongoing basis to inform Dr. Mirdamadi of the name of and contact information for my primary care physician and treating specialists, of any diagnoses I have received, and of any treatments I have had or am now undergoing for current conditions. And I also understand that it is important for me to let my primary care physician know about any recommendations and/or treatments performed by Dr. Mirdamadi in order to ensure that my care is properly coordinated.

No Guarantee and Patient Responsibility:
I understand that results from the Naturopathic Medical Treatments are not guaranteed and that Dr. Mirdamadi does not make any representations, promises, claims, warranties, assurances or guarantees that my medical problems or conditions will be helped by undergoing any of the Naturopathic Medical Treatments. I understand that my failure to comply with any treatment recommendations may impede results. I am responsible to disclose to Dr. Mirdamadi all medication, care, and assessments that I receive elsewhere and to provide medical records from other providers to ensure that care is coordinated and compatible.
I understand that the focus of naturopathic care is to alleviate the underlying conditions that can bring about illness rather than the treatment of symptoms. While I may experience some immediate improvement from the Naturopathic Medical Treatments, I understand that the most effective results occur when I make a long-term commitment to rebuild my health. It is my responsibility as a patient to follow-up with Dr. Mirdamadi within a recommended time period for evaluation of treatment results or to change treatment protocols as necessary.
Dispute Resolution: Disputes pertaining in any way to this document shall be decided not in court of law but through arbitration with the American Arbitration Association. Whoever initiates the arbitrations will be responsible to pay all costs of initiating it with the remainder to be paid by the non-prevailing party. The decision and award of the arbitrator shall be final and binding upon the parties.

CERTIFICATION OF CONSENT TO PROCEED WITH TREATMENT: I certify that I have read the foregoing Informed Consent for Naturopathic and Functional Medicine Evaluation and Treatment and including the nature of the proposed Naturopathic Medical Treatments and the potential risks, benefits and alternatives, and I have had the opportunity to ask questions about its contents. By voluntarily signing below I state that I have weighed the risks and benefits involved in undergoing the above listed Naturopathic Medical Treatments and consent and agree to receive the Naturopathic Medical Treatments as determined in my best interest by Dr. Mirdamadi. I intend this Informed Consent to Naturopathic Evaluation and Treatment to cover the entire course of my naturopathic care with Dr. Mirdamadi for any present or future conditions. I understand that I am free to withdraw my consent and to discontinue participation in the Naturopathic Medical Treatments with Dr. Mirdamadi at any time but that discontinuing consent does not remove past consent for therapy or treatments already consented to, or participated in with Dr. Mirdamadi.