Pediatric Intake Paperwork Logo
  • Pediatric Intake Paperwork

    For children up to age 12
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  • Personal Medical History

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  • Family Medical History

    Do any of your immediate family members suffer from any of the following conditions:
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  • Does your child have any problems with the following body systems: 

  • Please use the space below to elaborate further on each of the body systems you selected above:

  • Lifestyle

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  • Terms of Consent for Care

  • hereby authorize Dr. Marinaro to perform the following specific
    procedures as necessary to facilitate my child’s diagnosis and treatment:

    Common diagnostic procedures: e.g., venipuncture, radiology, laboratory, X-ray, paps

    Minor office procedures: e.g., cleaning, dressing a wound, ear lavage, skin scraping

    Medical use of nutrition: therapeutic nutrition, nutritional supplementation, and intramuscular vitamin injections.

    Botanical medicine: plant substances may be prescribed as teas, alcohol-based tinctures, glycerites, capsules, tablets, creams or suppositories

    Homeopathic medicine: the use of highly dilute quantities of naturally occurring plants, animals and minerals

    Craniosacral Therapy, Visceral Manipulation: gentle forms of bodywork used to address back pain and other musculoskeletal complaints, headaches and organ dysfunction

    Counseling: utilization of mental health counseling and techniques

    Medical use of Ozone Therapy: therapeutic ozone gas administered to isolated parts of the body, combined with depuration in an ozone sauna and injected subcutaneously or intramuscularly to address chronic pain and infections

    I recognize the potential risk and benefits of these procedures as described below:

    Potential risks: allergic reactions to prescribed herbs and supplements, side effects of medications or vaccinations, aggravation of pre-existing symptoms, discomfort, pain, infection, burns, nausea, light headedness, inconvenience of lifestyle changes, injury from injections, venipuncture or procedures. Please notify Dr. Marinaro if you experience any symptoms which may be secondary to the above procedures.

    Potential benefits: restoration of health and the body’s maximal functional capacity without the use of drugs or surgery, relief of pain and symptoms of disease, assistance in injury and disease recovery, and prevention of disease or it’s progression.

    Notice to Pregnant Women: All female patients must alert the doctor if they know or suspect that they are pregnant as some of the therapies used could present a risk to the pregnancy.

    With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by physician, or any personnel regarding cure or improvement of my condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time.

    I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others unless so directed by myself or my representative or unless it is required by law. I understand that I may look at my medical record at any time and can request a copy of it by paying the appropriate fee. I understand that my medical record will be kept for a minimum of seven years, but no more than ten years after the last day of my visit. I understand that information from my medical record may be analyzed for research purposes, and that my identity will be protected and kept confidential. I understand that any questions I have will be answered by my practitioner to the best of his/her ability.

    I understand that all sales of goods and services are final. Refunds for supplements up to 90 days after purchase (unopened items only).

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  • Integrative Concierge Care Policies

    Please read and initial the following statements below and sign/date at the bottom
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