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The Lester Clinic of Integrative Medicine

www.lesterclinic.com
ADULT PATIENT REGISTRATION FORM

~ Please Print ~
Name _________________________

Last First Middle


Birth Date _____________ _____ Male______ Female______

Address City State Zip


Home Phone ( ) Daytime Phone ( )


Social Security # Cell Phone ( )


Marital Status: Now Married____/ Never Married____/ Divorced____/ Widowed____/ Sig Other____/

Employment
Work Address Occupation
Type of Insurance: Independent_____/ PPO_____/ HMO_____/ Medicare_____/ None_____/
Name of Insurance Company

Referred By or How You Found Us



IF SOMEONE OTHER THAN PATIENT IS RESPONSIBLE FOR PAYMENT:
Name Relationship
Employed By Social Security #
Home Phone Work Cell

PERSON TO CONTACT IN CASE OF EMERGENCY:
Name Relationship Phone

CANCELLATION POLICY:

INITIAL APPOINTMENTS ARE NOT TO BE CANCELLED WITHIN 5 BUSINESS DAYS OF THE APPOINTMENT. THESE VISITS ARE SIGNIFICANTLY LONGER THAN ROUTINE VISITS AND CANNOT BE FILLED ON SHORT NOTICE. ROUTINE APPOINTMENTS ARE NOT TO BE CANCELLED WITHIN 24 HOURS. THERE WILL BE A CHARGE FOR LATE CANCELLATION OR MISSED APPOINTMENTS.

PAYMENT IS DUE AT TIME OF VISIT BY EITHER CASH, CHECK, OR CREDIT CARD.

WE REQUIRE you or others accompanying you to NOT wear colognes, perfumes, scents, essential oils, or scented lotions to the office. We keep a scent free office for people with sensitivities.

PLEASE SIGN AND RETURN AT LEAST ONE WEEK PRIOR TO YOUR APPOINTMENT.

I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE THE ABOVE & FOLLOWING INFORMATION IS CORRECT. I UNDERSTAND THE CANCELLATION POLICY AND PAYMENT POLICY. I HEREBY CONSENT TO MEDICAL AND HOMEOPATHIC TREATMENT BY DR. JEFF D. LESTER, D.O.



Signature Date

ADULT HOMEOPATHIC REGISTRATION FORM

Name Date

Last First Middle

=====================================================================================================================

CURRENT PROBLEMS: Date of Onset:

1.

2.

3.

4.

5.


PAST PROBLEMS: Dates:
1.

2.

3.

4.

5.
FURTHER DESCRIPTIONS OF PROBLEMS:






SURGERIES: Dates:

1.

2.

3.

4.

5.


HOSPITALIZATIONS: Dates:

1.

2.

3.

4.

ADULT HOMEOPATHIC REGISTRATION FORM

Name Date

Last First Middle

=====================================================================================================================


CURRENT MEDICATIONS DATE BEGAN: CURRENT HERBS, VITAMINS

& DOSAGE: & DOSAGE:






PAST MEDICATIONS &DOSAGE: DATE BEGAN: DATE STOPPED:










CURRENT OVER THE COUNTER MEDICATIONS”
TOPICAL MEDICATIONS (ie, cortisone):
Any prior constitutional Homeopathic medications: Prescribed By: Result (+ or -):


ALLERGIES TO MEDICATION: REACTION:


TOBACCO USE: Never / or How Much _______ How Long _________ When ___________

COFFEE USE: ALCOHOL USE: Present:

Past:

LIVING SITUATION: (Members at Home)

NAME AGE RELATIONSHIP

1.

2.

3.

4.

5.



ADULT HOMEOPATHIC REGISTRATION FORM

Name Date

Last First Middle

=====================================================================================================================

FAMILY HISTORY:
PERSON AGE (alive/deceased) HEALTH PROBLEMS

FATHER:

MOTHER:

SIBLINGS: (Brother or Sister)


OTHER ILLNESSES THAT RUN IN THE FAMILY LINEAGE:


ENVIRONMENTAL ALLERGIES:

Substance Reaction




REVIEW OF SYSTEMS -- Give Details to be Discussed
MIND: Describe any Difficulties Emotionally or Mentally









ADULT HOMEOPATHIC REGISTRATION FORM

Name Date

Last First Middle

=====================================================================================================================

HEAD, EYES, EARS, NOSE & THROAT:


RESPIRATORY:


CARDIOVASCULAR:


GASTROINTESTIANL: (Any Scoping with Dates)


RECTAL TROUBLE: (Constipation, Diarrhea, Anal Itching, Fissures, Hemorrhoids)


URINATION:


SEXUALLY TRANSMITTED DISEASES: DATE TREATMENT


BIRTHS OR ADOPTIONS: (Son or Daughter & Date)


MISCARRIAGES / ABORTIONS: (Number & Date)


GYNECOLOGICAL / PROSTATE / TESTICAL, ETC: (Any Troubles & Date Last Checked)



ADULT HOMEOPATHIC REGISTRATION FORM

Name Date

Last First Middle

=====================================================================================================================

DERMATOLOGICAL: (Rashes, Sweat, Acne Treatments)


SPINE & EXTREMITIES: (Specify Neck or Back Abnormalities, ie- Cramping/Pain/Numbness)


BONE DENSITY TESTS:


SLEEP:


DREAMS: (Recurrent Themes)


ENERGY: (When Low & High)


TEMPERATURE: (Generally feel warm or chilly)


TIME OF DAY PROBLEMS OCCUR:


OTHER:





Dr. Jeff D. Lester, D.O.

The Lester Clinic of Integrative Medicine


65 Aspen Way, Watsonville, CA 95076

(831) 724-1164 – phone
(831) 724-1252 – fax
drlester@lesterclinic.com


3700 Thomas Rd. #207, Santa Clara, CA 95054
(408) 844-0010 – phone
(408) 844-0013 – fax
lesterclinic@gmail.com


______________________________________________________________________________


Email Policy & Agreement
Email is a welcome way to consult with our office regarding problems and questions.

However, no emergency material is to be communicated by email.
Because of the time required for our Physician to read and respond to emails communications, the following fees will apply: Half-page = $20.00 / Full-page = $40.00

There is no charge for the Staff to receive emails regarding setting up appointments or sending remedies.


Remedies by Mail
Homeopathic remedies can be sent to you by mail, by the following procedures;
1) Call or email us stating which remedies are needed, ie- name & dose (daily/booster/high).
2) Include your credit card number if not already on file. For timeliness & efficiency,
arrange to have your card on file (your number will be privacy-protected).
3) Shipping & handling in most cases is a flat-rate of $4.
Most major credit cards accepted (Visa, MasterCard, American Express, etc)


credit card number expiration date

I understand & agree with the above policies.






Name Date


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