Pediatric Patient Intake Form

Pediatric Patient Intake Form
Please Note:
This form will take approximately 10 minutes to complete.
Several consent and policy forms within the intake will require your E-Signature.
Please do not print these forms. Please fill them out online 24 hours before our visit. We are a Paperless Practice utilzing Electronic Health Records.
All information is Confidential.
Page 1 of 13

Cancelation Policy:
Please mark the date of your Appointment on your calendar. While we make every effort to remind our clients of appointments by email and phone two or more days prior to the appointment, it is the client's responsibility to maintain his or her schedule. Missed appointments will be invoiced at full cost. Extenuating circumstances will be reviewed on a case-by-case basis. A strict twenty-four hour (1 full business day) notice via voice mail and email are acceptable. Advance notice allows us to better accommodate our clients on the waiting list. Thank you for your cooperation.
Signature*
Clear
Page 2 of 13

Patient Consent Form for Collection, Use, and Disclosure of Personal Information
Privacy of your personal information is an important part of Erica L. Robinson, NDs practice, while providing you with quality naturopathic care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We will try to be as open and transparent as possible about the way we handle your personal information.
All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are trained in the appropriate use and protection of your information. All electronic forms and consent forms are viewed only by Erica L. Robinson, ND unless you have specifically signed a Release of Records to make these forms available to another Health Care Provider or family member. In-office forms at The World Of My Baby are utilized by the staff of the centre and adhere to the appropriate use and protection of your information.

Our Privacy Policy at Erica Robinson NDs practice outlines what we are doing to ensure that:
- Only necessary information is collected about you;
- We only share your information with your consent;
- Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols;
- Our privacy protocols comply with privacy legislation and standards of our regulatory body, the Board of Directors of Drugless Therapy - Naturopathy.
How our Clinic Collects, Uses and Discloses Patients’ Personal Information:
The Clinic / Practice of Erica Robinson ND understands the importance of protecting your personal information. To help you understand how we are doing that, we have outlined how the clinic is using and disclosing your information.
The clinic will collect, use and disclose information about you for the following purposes:
- To assess your health concerns
- To provide health care
- To advise you of treatment options
- To establish and maintain contact with you
- To send you newsletters and other information mailings
- To remind you of upcoming appointments
- To communicate with other treating health-care providers
- To allow us to efficiently follow-up for treatment, care and billing
- To complete claims for insurance purposes
- To invoice for goods and services
- To process credit card payments
- To collect unpaid accounts
- To comply with all regulatory and legal requirements including court orders, statutory requirements to advise authorities of child abuse and reporting diseases and individuals who may be an imminent threat to harm themselves or others
- To use for educational and research purposes (this includes case summaries, photographs, lab results and other pertinent medical information). Your identity will be protected at all times and if necessary, identifying information will be altered to protect your privacy in all the above instances
By signing this Patient Consent Form, you have agreed that you have given your consent to the collection, use and/or disclosure of your personal information as outlined above.
Patient Consent:
I have reviewed the above information that explains how Erica Robinson ND will use my personal information and the steps that the centre / clinic is taking to protect my information.
I agree that the Erica Robinson ND can collect, use and disclose personal information as set out above in the information about the clinic / centres’s privacy policies.
Full Name*
First NameLast Name
Date
MonthDayYear
I have reviewed the above information that explains how Erica Robinson ND will use my personal information and the steps that the centre / clinic is taking to protect my information. I agree that the Erica Robinson ND can collect, use and disclose personal information about (the signed) as set out above in the information about the clinic / centres’s privacy policies. Signature*
Clear
Page 3 of 13

Informed Consent
Please note that this form must be signed prior to your first appointment.
Naturopathic medicine is the treatment and prevention of diseases by natural means. Naturopathic Doctors assess the whole person, taking into consideration physical, mental, emotional and spiritual aspects of the individual. Gentle, non-invasive techniques are generally used in order to stimulate the body’s inherent healing capacity. Your clinician, Erica Robinson ND, will take a thorough case history, perform a physical examination, which can include a breast exam, and take blood and urine samples. If your case requires, the physical may include more specific examinations such as gynecological, rectal, prostate or genital exams.
It is very important that you inform your Naturopathic Doctor immediately of any disease process from which you are suffering and any medications/over the counter drugs that you are currently taking. Please advise your Naturopathic Doctor immediately if you are pregnant, suspect you are pregnant or if you are breast-feeding.
As a patient you will receive information about your diagnosis and/or treatment, alternative courses of action, the material effects, costs, expected benefits, risks, side effects and in each case the consequences of not having the diagnosis and/or treatment acted upon.
The staff is trained to handle emergencies should the need arise.
There are some slight health risks associated with treatment by naturopathic medicine.
These include but are not limited to:
- Homeopathic remedies may occasionally result in the aggravation of pre-existing symptoms. When this occurs the duration is usually short.
- Some patients experience allergic reactions to certain supplements and herbs. Please advise your clinician of any allergies you may have.
- Pain, bruising or injury from venipuncture or acupuncture or parental therapy.
- Fainting or puncturing of an organ with acupuncture needles or accidental burning of the skin from the use of moxa.
- Muscle strains and sprains or disc injuries from spinal manipulation.
- There is a very small potential for stroke in neck manipulation. Patients are thoroughly screened by the clinician prior to manipulating the neck.
- The staff and Erica Robinson ND are trained to handle emergencies should the need arise.
I understand:
- The clinic does not guarantee treatment results.
- That Erica Robinson ND will explain to me the exact nature of any treatment provided and will answer any questions I may have.
- I am free to withdraw my consent and to discontinue treatment at any time.
Full Name (of Patient)*
First NameLast Name
Full Name (of Guardian)*
First NameLast Name
Date
MonthDayYear
Signature of Patient or Guardian Indicating that they have read and agree to Informed Consent*
Clear
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Email Consent
This section is in accordance with Canada's New Anti-Spam Legislation that came into effect July 1, 2014
In order to contact patients about clinic changes, promotions, products, events, newsletters, workshops and programs, we require your consent below. You may choose to withdraw consent at any time and you will no longer receive emails from Erica L. Robinson, ND or The World of My Baby.
Dr. Erica L. Robinson, Naturopathic Doctor
At The Bronte Naturopathic Clinic
400 Bronte St S Unit 215
Milton, ON L9T 1R8
905-940-6340
info@drrobinson.ca / questions@drrobinson.ca
www.drrobinson.ca
I consent to being emailed by Dr. Erica L. Robinson ND for purposes of learning of changes in the clinic / centre*
Clear
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Communication Policy
I want to provide you with support on your healing journey, and I endorse transparency and setting expectations up front so we are both on the same page with what I can provide outside of our visists together. This is our Communication Policy:
- Questions are not answered on Text Message or Social Media Platforms for legal reasons
- Email poses security risks. To ask questions online, please utilize the Secure Messaging System through Patient Fusion. Questions will be answered by my next business day.
- Urgent Questions: call the Office at 905-940-6340 and leave a message with my Assistant Lori. She will call you back as soon as possible with the answer I provided
- Complex questions and new concerns: please book a 15 or 30 minute follow-up visit so I can provide you with the naturopathic support you deserve
I Understand the Communication Policy*
Clear
Page 6 of 13

Nutrition / Diet
Was your infant:
BreastfedFormula-fedOther
How Long?
Which foods were introduced before six months?
Which foods were introduced from 6 - 12 months?
Did your child ever experience colic?
YesNo
How Severe?
MildModerateSevere
Does your child have any dietary restrictions? (Religious, vegetarian / vegan, etc)?
Typical Breakfast
Typical Lunch
Typical Dinner
Snacks
Beverages and Quantity

Health & Development
How was your child's health in the first year?
PoorFairGoodExcellentUnknown
At what age did your child first:
Sit Up?
Crawl?
Walk?
Talk?
Describe your child's sleep pattern? Time to bed, awake, naps, nightmares?
How would you describe your child's temperament?
How would you describe your child's behaviour and performance at school?

Are there any lab reports, pictures of your condition, diet diaries, or review of systems to upload? Please do so here - File 1
Upload a File
Cancelof
Are there any lab reports, pictures of your condition, diet diaries, or review of systems to upload? Please do so here - File 2
Upload a File
Cancelof
Are there any lab reports, pictures of your condition, diet diaries, or review of systems to upload? Please do so here - File 3
Upload a File
Cancelof

Last Question!
How do you view the investment in your child's health?
I really just have an acute concern about my child that I need help addressingI see the importance in having a health care team for my child and getting growth and development check ups even when they are not illInvesting in my child's health is as important as investing in their education - it is their future. I would like them to have access to natural healthcare options when needed, and I see the importance of growth and development check ups even when they are not ill
Should be Empty:

Pediatric Patient Intake Form

Cancelation Policy:

Patient Consent Form for Collection, Use, and Disclosure of Personal Information

Informed Consent

Email Consent

Communication Policy

Demographic Information

Prenatal Health

Birth History

Health & Development