Remove the below once the form is finalised. — WPfG
Education:
Brenna Hatami obtained her BA in International Studies from University of Colorado Boulder in 1987, her naturopathic doctorate from the Southwest College of Naturopathic Medicine in 1997 and her BSN from the University of Colorado Anschutz Medical Center in 2020. She maintained her Vermont license from 1987-2014 and has been registered as a Naturopathic Doctor in Colorado as of June 1st, 2014. Colorado Naturopathic License # 0000009.
Colorado RN license # 1672151
FEES:
First Office call (60-90 minutes) $225.00
Return Office Call (45-60 minutes) $100.00
Phone call (20-30 minutes) $75.00
All clients are asked to pay in full at the time of the visit. I can provide an itemized receipt with ICD codes for you to submit to your insurance carrier for possible reimbursement or for your HSA account.
24-hour notice is required for all cancellations. Missed appointments without 24 hours notice will be charged a $75.00 cancellation fee. Extra expenses for supplements or herbs are in addition to the cost of the appointment.
I have read the above information, and my signature endorses my understanding of the conditions for working together.
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Signature Date
Welcome.
To comply with state regulations regarding the practice of naturopathic medicine issued by Colorado Department of Regulatory Agencies, we must ask all patients to read and sign the following:
SERVICES:
Naturopathic Medicine is a branch of the healing arts distinct from other branches. Our services include the prevention, evaluation, diagnosis and treatment of injuries, diseases and conditions through education, nutrition, naturopathic preparations, natural medicine, physical agents and other therapies and modalities designed to support the body’s natural healing process. Naturopathic Doctors are registered under the Colorado Naturopathic Doctors Act. They are not Medical Doctors (MD), Doctors of Osteopathy (DO), Doctor of Chiropractic (DC) or Doctor of Nursing (DNP) who are licensed under separate acts. Naturopathic Medicine is not meant to be a substitute for conventional medicine. As Naturopathic Doctors in Colorado, we do not prescribe, dispense, administer or inject controlled substances or practice medicine. We cannot recommend against a course of care recommended or prescribed by a license provider in another branch of the healing arts.
RISKS:
Naturopathic Medicine is generally considered safe but may involve some risks including, without limit: all the risks disclosed with any preparations or medicines: allergic reactions, infection, pain or discomfort, weakness, fainting, nausea, skin irritations, (including discoloration or scaring) aggravation of symptoms, mood changes and rarely neurological injury and pneumothorax. Naturopathic Medicine may adversely interact with specific drugs and may be in appropriate during pregnancy. Naturopathic manual therapies involve risks including, without limit, fractures, disc injuries, dislocations and sprains. Additionally, hidden conditions may exist that are not detectable through examination.
EMERGENCIES:
If you are having a medical emergency, do not wait to seek care. Call 911
NO GUARANTEE:
Every individual responds differently to care and no guarantee or assurance is made as to the results of care in any specific case, as care may not improve in your condition.
Alternatives and Collaboration:
Alternatives to Naturopathic Medicine include declining such are and consulting with other providers such as an MD, DO, DC or CNP. Naturopathy is not a substitute for other types of health care and I encourage you to seek other opinions and have a relationship with and MD or DO and also to communicate with all your providers about the care recommended by me. I encourage collaboration with your other providers. If applicable, please list the providers with whom you give your permission and directive to collaborate.
Providers names, phone number and addresses:
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Payment, Insurance and Refunds:
Payments are due in full at time of service and are not conditional on response to care. There is no guarantee of insurance coverage. Any insurance you have is an agreement between you and your insurance provider. You may terminate care at any time. Any prepaid services are eligible for a refund within 6 months. No refunds are available for product purchases.
Acknowledgement for Consent for Services:
Do not sign until you have read and fully understand this consent and understand that I should not sign this form if any of my questions have not been explained to my satisfaction or if I do not understand any of the terms or words.
I have read the above information, and my signature endorses my understanding of the conditions.
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Signature Date