BAINBRIDGE NATUROPATHIC CLINIC
Dr. Christina Hinchcliffe, ND
123 BjuneDr, Suite #111
Bainbridge Island, WA 98110
P: (206)842-2278 / F: (206)842-5206 /

Welcome to Bainbridge Naturopathic Clinic. We will do our best to serve your healthcare needs, provide natural and safe treatments, and serve as a resource for natural health education. It is important to us that you read and understand our clinic policies. If you have questions about the policies, please be sure to ask. We encourage you to communicate any issues, complaints or special needs with us.

CLINIC POLICIES

PAYMENT Payment is due at the time of service for office visits (non-insurance), copays and dispensary items. We accept cash, checks, debit cards, health savings account (HSA) cards, Visa, Mastercard, and American Express. Payment plans and sliding scales are available upon request.
INSURANCE It is your responsibility to make sure that your insurance policy covers the treatment you are receiving. Please call your insurance company before your visit and get specific information regarding your policy coverage.
If you are unable to find this information, please ask us and we can help you make sense of your insurance. Please do this before your appointment to avoid unnecessary costs.
There are treatments we may do that aren’t covered by insurance, in which case you will be responsible for payment. We will try to let you know before we perform any “uncovered services,” but they vary from plan to plan and sometimes we are unaware that a specific plan won’t pay, in which case it will be your responsibility.
I understand that I am financially responsible for all charges and agree to pay for services. If applicable, I authorize the provider to release to my insurance company any information necessary to process a claim. I authorize the insurance payment be made directly to the provider.

Initials ______Date ______
SUPPLEMENTS We stock a dispensary in our office and will recommend items that you can buy here. However, we may also recommend you go elsewhere and you are not obliged to purchase directly from Bainbridge Naturopathic Clinic. When you need refills, please call a few days ahead to make sure we’ve got your items in stock. Sometimes, due to vendor back orders or other circumstances, we will not be able to get the same item and will give you a similar product as a substitute.
If you need to pick items up when we are not in the office, we have a pick-up box outside of the clinic where we will leave items for you when appropriate.

CONTACT US We prefer to be contacted via our main phone at (206) 842-4841 or fax (206) 842-5206. You can also email for general information at . However, we cannot provide confidential information via this email address. You can also send emails to and Dr. Hinchcliffe can send you a confidential secure reply. We are in the office Tuesday-Friday from 9-5. Ashlee, our office manager, answers the phone from 9-3, but we will retrieve messages left up to 5 every day.
If you have an urgent need to reach us after hours or during off days, follow the steps on the voicemail prompt at our regular phone number of (206) 842-4841 in order to reach us.
CANCELLATION POLICY We are a small clinic and do our own scheduling. We appreciate if you give us at least 48 hours notice before canceling an appointment so we have sufficient time to fill that spot. Since we dedicate 30 minutes to 1 hour of our time for your appointment, if a time spot is empty as a result of your late cancellation, it hurts our business. For this reason, if you cancel your appointment with less than 48 hours notice, there is a $50.00 charge for your empty time slot. This is charged to you, not your insurance. The charge will only be waived in emergency situations.
I have read and understand that if I cancel within 48 hours of an appointment, I will be liable for a $50.00 cancellation charge.

Initials ______Date ______
NO SHOW POLICY If you make an appointment and don’t call or show up for that appointment (barring emergency situations in which a call cannot be made) there is a charge of $50.00. This is charged to you and not your insurance. We reserve the right to discontinue care to patients who no show and/or have a late cancellation for three appointments.
I have read and understand the “No Show” policy and understand that if I fail to show up at my scheduled appointed time, I will be charged $50.00.

Initials ______Date ______
CONFIDENTIALITY You have the right to know how your privacy is being protected in accordance with the HIPAA Act of 1996. Your healthcare information is private and cannot be shared with anyone else without your signed consent. Your records are kept in your chart and secured in our clinic at all times. If charts are in the open, names are covered. Access to the clinic is limited to practitioners, employees, and supervised guests.
I have read and understand my right to privacy, as stated above, and agree to allow Bainbridge Naturopathic Clinic to maintain my records confidentially in accordance with the law.

PATIENT SIGNATURE ______DATE ______

NEW PATIENT INTAKE FORM
PATIENT INFORMATION
Name ______Date of Birth ______Age______Address ______City ______State _____ Zip ______
Home Phone ______Cell______Work______Email ______Social Security Number ______
Relationship Status: _____Married/Partnered _____Divorced/Separated _____Single/Widowed
Live with: ____Spouse ____Partner ____Relative/s ____Friend/s ____Parent/s ____Kid/s ____Pet/s
Emergency Contact ______Phone ______
How did you hear about us? ______

Would you like to receive a copy of Dr. Hinchcliffe's bimonthly newsletter and updates on her blog posting via email? Y / N
EMPLOYMENT INFORMATION
Employer ______Position ______
Address ______Phone ______
INSURANCE INFORMATION
Insurance Company/Plan Name ______
ID Number/Claim Number ______Group Number ______
Insurance Phone ______Whose Policy is this (circle): Self Spouse Other
(If not self, please list name & date of birth of policy holder) ______

It is your responsibility to familiarize yourself with your insurance policy. If you are unsurewhether you have naturopathic coverage, please call your insurance company or check online to verify. It is important to know if you have a deductible, if you have preventative care coverage, and which labs are covered by your insurance. Copays are due at the time of service. Supplements are not covered by insurance.
_____ (initial) I understand that I am financially responsible for all charges and agree to pay for services not covered by insurance.
_____ (initial) I authorize the provider to release to my insurance company or companies, any and all
information necessary to process any claim. I further authorize that payment/s be made directly to the provider.

CONFIDENTIALITY You have the right to confidentiality when receiving care from providers. We will not disclose medical information to anyone unless directed to do so in writing by you. If you would like us to leave messages regarding your health care on an answering machine or with another person, please list them below and indicate which voice mail we may leave messages on:

PATIENT SIGNATURE ______DATE ______

YOUR CURRENT HEALTH
What is your main reason for coming in today? ______
MEDICAL HISTORY
What childhood illnesses have you had? ______
______
What adult illnesses have you had? ______
______
Previous surgeries and hospitalizations (include approximate dates): ______
______
Do you have any allergies to any drugs, herbs, foods, animals or other? ______
______
CURRENT MEDICATIONS/SUPPLEMENTS
Please list any medications, vitamins, herbs, supplements, or over-the-counter products you are taking: ______

PATIENT SIGNATURE ______DATE ______

FAMILY HISTORY OF HEALTH PROBLEMS (and age of death, if applicable)
Your Mother ______
Your Father ______
Your Siblings ______
Maternal Grandparents ______

Paternal Grandparents ______
Children ______

PERSONAL HABITS
What do you enjoy most in your life? ______
What are your main interests or hobbies? ______
Do you regularly use alcoholic beverages, how much? ______
Do you smoke (how much & for how long)? ______
Do you use recreational drugs (which & how much)? ______
How often do you watch television? ______
Do you have a religious or spiritual practice? ______
Do you enjoy your work? ______Do you take vacations? ______
Do your work or hobbies expose you to toxic chemicals, heavy metals, mold or second hand smoke?

STRESS
On a scale of 1-10 (10 being high), how do you rate your average stress level? 0 1 2 3 4 5 6 7 8 9 10
What are the most significant stressors in your life or areas of disharmony?

SLEEP
On a scale of 1-10 (10 being great), how do you rate your sleep? 0 1 2 3 4 5 6 7 8 9 10
Do you have problems falling or staying asleep (which)? ______How many hours do you sleep at night? ______Do you awaken refreshed?______

ENERGY
On a scale of 1-10 (10 being great), how do you rate your energy? 0 1 2 3 4 5 6 7 8 9 10
Are your daily tasks affected by your being tired? ______

EXERCISE
What type, how much, & how often do you exercise? ______

DIET
Do you follow a special diet? ______Do you eat at least 3 meals a day? ______Are you satisfied with your diet? ______How much water do you drink daily? ______
Do you drink soda or juice? N / Y, How much? ______Do you take in caffeine? N / Y, How much? ______Please list the foods/amounts you’ve eaten in the past 24 hours: ______

PATIENT SIGNATURE ______DATE ______

HEALTH CONCERNS (Please circle all items that are current or recent)
GENERAL: fever, night sweats, fatigue/tiredness, unusual weight gain or weight loss, appetite changes, eating disorder, poor sleep, strong thirst, cravings, swelling of lymph nodes, food sensitivities or allergies, cancer (if yes, what type ______)

SKIN, HAIR, NAILS: rash, infection, growths/bumps, hair loss, itching, thinning/sensitive skin, acne, oily, sores/lesions, eczema, sensitive skin, nail infection, dry hair, thin/brittle nails, ridged nails

HEAD, EYES, EARS, NOSE, THROAT: frequent headaches, migraines, vision problems, eye pain, double vision, floaters/spots, eye redness/watery eyes, tearing problems, hearing loss, ringing, earache or ear pain, itchy ears, hearing aids, frequent colds or flus, sinus problems or drainage, post nasal drip, hay fever/allergies, loss of taste or smell, snoring, frequent sore or dry throat, hoarseness, sore or swollen tongue, mouth or lip sores, dental problems, TMJ

CENTRAL NERVOUS SYSTEM: head injury, light-headedness, dizziness, convulsions, weakness/paralysis, balance disturbance, trouble speaking

MUSCULOSKELETAL: joint or muscle pain/stiffness (if yes, where______), injury, muscle cramps/spasms, muscle weakness, bone loss, loss of muscle mass

PERIPHERAL NERVOUS SYSTEM: loss of sensation or feeling in a body part, pins and needles sensations in a body part

CARDIOVASCULAR AND CIRCULATION: chest pain or discomfort, high blood pressure, heart murmur, palpitations, swelling, leg swelling, dizziness, history of heart attack or TIA/stroke/blood clots, history of angina/chest pain, history of rheumatic fever, easy bruising, tendency to bleed easily or difficulty stopping bleeding, nose bleeds, high cholesterol, varicose veins, spider veins, discolored extremities, paleness, anemia

RESPIRATORY: cough, sputum, wheezing/asthma, chest pain, shortness of breath, rib pain

DIGESTION: heartburn, ulcer, abdominal pain, nausea, vomiting, blood/food/mucus/oil in stools, black tarry stools, abdominal bloating, belching, excessive gas, bad breath, coating on tongue, hemorrhoids,hepatitis, polyps, constipation, diarrhea, last colonoscopy (and results) ______

GENITOURINARY: pain with urination, urgency, frequency, dribbling, incontinence, bladder infections, cloudy/foul smelling urine, kidney stones, blood in urine, urinating at night (if yes, how often?______), hernia, lower abdominal pain, sexually transmitted disease, urethral or genital discharge, genital sores

MALE: prostate inflammation, erectile difficulties, testicular pain or swelling, last digital prostate exam (and results) ______, last PSA blood test (and results) ______

MENTAL-EMOTIONAL: depression, mood swings, anxiety, irritability, tearfulness, nervousness, tension, phobias, compulsive behaviors, psychiatric disorder, suicidal thoughts/plan, diagnosed with or possible alcohol/drug dependency, worry, relationship problems, abusive relationship, elevated stress, ADD/ADHD

ENDOCRINE: low thyroid function, overactive thyroid function, enlarged thyroid, thyroid with nodules, low temperature, hot flashes, diabetes, low blood sugar, high blood sugar, sugar or salt cravings, difficulty perspiring, rapid aging

FEMALE: heavy bleeding, painful bleeding, clots, PMS, PCOS, infertility, lack of bleeding, irregular cycles, odor, itching, painful intercourse, sexual dysfunction, breast pain/lumps, lack of sex drive, fibroids, ovarian cysts or PCOS, abnormal hair growth, birth control pills or injections, vaginal dryness, hysterectomy (total or partial?), age of first period ___, age of last period___, number of pregnancies___, number of children (ages) ______, last pap (and results) ______, last breast imaging (and results) ______, last bone density scan (and results) ______

PATIENT SIGNATURE ______DATE ______

FINAL SIGNATURE/STATEMENT

“I______have asked Dr. Christina Hinchcliffe, ND, of Bainbridge Naturopathic Clinic, for help and I understand that the doctor will help to the best of her ability.”

PATIENT SIGNATURE ______DATE ______

DOCTOR SIGNATURE ______DATE ______

Bainbridge Naturopathic Clinic – (206)842-4841 –