PATIENT FORMS


 
 


If you continue following the same course of treatment you have been following, will your results really change? Have you ever wondered if you are on your true path to achieving optimal health? Sometimes it requires taking a new & improved road to reach your goal. Are you ready? 
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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 on what to expect, Dr. Varela would appreciate that you read the below steps & provide your signature. This would simply imply that you have read the Patient Acceptance Policy & understand what is expected of you.

1. Please complete the following form prior to your visit and bring it in with you or return it via e-mail.

INITIAL INTAKE FORM

MEDICAL RECORDS RELEASE FORM

For your child:

INITIAL INTAKE FORM FOR CHILD

2. Please bring Medical records and/or test results from previously seen physicians. Must be sent at least 7 days prior to your appointment date to: 

Dr. Toni Varela, NMD.
939 Hartz Way, Suite 100.
Danville, CA 94526
Fax #: 925-553-7266
 

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. And Please bring copies to leave at the office.

3. Bring your medications & supplements (or a list of the ones you are currently taking, if any), so we may review them.

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.

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
 

I will review each prospective test with you, what the cost is & why it is necessary for me 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 lasts approximately 45 minutes. Upon review of your results, I can determine whether I can fully help you, create a customized treatment plan for your specific needs; or I will refer you to another specialist who can. I'll explain everything 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 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 getting better.

8. If you are taking hormone replacement therapy (HRT) or thyroid medication, you must be seen by Dr. Varela every 3 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, 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!