Before your first visit, you can save time by filling out the appropriate forms.

NATUROPATHIC MEDICINE – NICOLA DEHLINGER, ND

 

LOCAL PATIENT FORMS

Confidential Health Questionnaire

Notice of Privacy Practice

Acknowledgment of Privacy Practices

Patient Consent Form

Financial Policy

Disclosure Statement

Authorization for Credit Card

Authorization to Share Information (Optional)

Confidential Health Questionnaire

Notice of Privacy Practice

Acknowledgment of Privacy Practices

Patient Consent Form

Financial Policy

Disclosure Statement

Authorization for Credit Card

Authorization to Share Information (Optional)

 

**FOR FEES PLEASE REFER TO THE FINANCIAL POLICY**

Dr. Nicola does not accept insurance; however, she can provide a coded super bill at the time of service. Reimbursement depends on your insurance policy.

THERAPY & YOGA – SHELLEY NIELSEN, LCSW & RYT200

FORMS

Disclosure and Responsibilities

New Patient Intake

Authorization for Release of Information

Consent for Online/Telehealth Therapy

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NON-LOCAL PATIENT FORMS

Confidential Health Questionnaire

Notice of Privacy Practice

Acknowledgment of Privacy Practices

Patient Consent Form

Financial Policy

Disclosure Statement

Authorization for Credit Card

Authorization to Share Information (Optional)

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**FOR FEES PLEASE REFER TO THE FINANCIAL POLICY**

Dr. Nicola does not accept insurance; however, she can provide a coded super bill at the time of service. Reimbursement depends on your insurance policy.

THERAPY & YOGA – SHELLEY NIELSEN, LCSW & RYT200

FORMS

Disclosure and Responsibilities

New Patient Intake

Authorization for Release of Information

Consent for Online/Telehealth Therapy