PATIENT FORMS

CONSENT FORMS
 

Before your visit, please review the Patient Acceptance Policy.

In order to best serve you, carefully review the Patient Acceptance Policy. It is Dr. Varela's opinion that you should be well informed on our expectations & clinical procedures. To prevent any misunderstandings or confusion of what to expect, Dr. Varela would appreciate that you read the below steps prior to making an appointment. Booking an appointment requires that you consent to the Patient Acceptance Policy & understand what is expected of you.

1. Please complete an appropriate intake form prior to your visit + e-mail it to info@drtonivarela.com.

INITIAL INTAKE FORM (Online version available here)

MEDICAL RECORDS RELEASE FORM

For your child:

INITIAL INTAKE FORM FOR CHILD(13-17years old)

INITIAL INTAKE FORM FOR CHILD(6-12years old)

INITIAL INTAKE FORM FOR CHILD(Birth-5years old)

2. Please bring medical records and/or test results from previously seen physicians. In order to retrieve your results in a timely fashion, request your records at least 7 days prior to your appointment date. 

Any records you have within the past 12 months should be brought to your initial appointment. This may partially eliminate the need for us to order new tests for you, and thus may reduce your total cost for services. Please bring copies to leave at the office.

3. Bring your medications & supplements (or a list of the ones you are currently taking with their ingredients, reason for use & dosage regimen, if any) for review.

4. Please be ready to provide your pharmacy name, address, phone and FAX number.

5. Check with your insurance company about Out-of-Network lab coverage in order to see if any of your testing may be covered or reimbursed. 

6. Initial consultations last approximately 60-90 minutes. Available in-office, via phone, & internet. The first visit is very unique compared to most other medical offices. We will look at all body systems & how they work together. We take into account your history, lifestyle, stress level, your environment, family history, & many other factors to get an understanding of your overall health. We then use specialized lab testing to get more refined information about how your body's functioning & create an initial treatment plan. Our goal is to find the underlying causes of your health challenges.

ORDERING LAB TESTS

Each prospective test will be reviewed with you, what the cost is & why it is necessary to order them. The results take any time between a few days to a few weeks to return.

7. Follow-Up Consultations are available in-office, via internet, & phone. The 1st follow up appointment usually is made 2-3 weeks from the initial appointment & lasts approximately 45 minutes . Upon review of any test results, Dr. Varela can determine whether she can fully help you, create a customized treatment plan for your specific needs; or will refer you to another specialist who can. Everything will be explained to you thoroughly so that you can make a decision of how you wish to proceed. Concierge visits to a place more convenient to you may be discussed. 

Follow Up Consultations thereafter are usually scheduled every 3, 6, or 12 weeks allowing you the opportunity to discuss your progress & any concerns you have. Dr. Varela will at this time determine what direction to take to help you continue with your progress. Your cooperation in taking personal responsibility in your health care will go a long way in reaching your health goals.

8. If you are taking hormone replacement therapy (HRT) or thyroid medication, you must be seen by Dr. Varela every 3-6 months to review your progress & obtain a lab requisition to re-test in order to evaluate & refill your medication. Prescriptions for hormones, including thyroid, are authorized for 90-day increments. It is your responsibility to schedule follow-up appointments so that you do not run out of your medication. This policy is in place to reduce your risk of any ill-effects & so that we may monitor your progress & make any adjustments to your medications & dosages as needed. If you experience any change in symptoms regardless of where you are in the course of your treatment, please notify the office to schedule an appointment.

9. Unscheduled calls, texts, walk-in visits to the office, e-mails & treatment hours are not to be used in place of a consultation. Please keep all health concern discussions for scheduled consultations only. For privacy & consideration, medical advice & lab review will only be discussed during scheduled follow-up appointments. 

Thank You!