Forms

In attempt to recognize that your time is valuable we have provided you with all of the initial paperwork needed as well as some forms that would help our physicians to better track your progress.

The following forms are double sided to help conserve paper, please set your printer to duplex printing. If you don’t have this option available the forms will print single page. At the end of each of these intake forms is a terms of agreement, acknowledgment of privacy, and insurance policy, please be certain to sign each of these. Thank you.

1.) Adult New Patient

2.) New Patient Intake Child

3.) Acupuncture Informed Consent to Treat

 

The following forms are West Valley Naturopathic Center’s Insurance policy and a copy of our Private Practices. These forms are also double sided.

1.) Office Terms of Agreement
2.) Privacy Policy Summary
3.) Authorization to Disclose Protected Health Information
4.) Lab Results Patient Release Form

 

The following forms are to better assist your physician in tracking a variety of useful information.

1.) Blood Pressure Monitoring
2.) Medication List
3.) Exposure Questionnaire

 

Sports Physical Forms

Concussion in Youth Sports -A Fact Sheet for Parents

Concussion Symptoms Checklist

2015-2016 ANNUAL PREPARTICIPATION PHYSICAL EVALUATION

2015-2016 ANNUAL PREPARTICIPATION PHYSICAL EXAMINATION

AIA Mild Traumatic Brain Injury (MTBI) / Concussion Annual Statement and Acknowledgement Form

 

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