Patient information

Please read and acknowledge your understanding of the following items. If you do not understand something, please do not sign until you have clarified the point with Dr. Myatt. This form must be completed and returned prior to your initial consultation. Thank You!

Dr. Myatt's health consultations are NOT intended to replace the care of my primary medical physician. Her advice is intended to complement conventional care when appropriate and to offer alternatives to conventional care when appropriate.

I have read and I understand the above.

SIGNED_________________________________Date_______________

Medicare does not reimburse for naturopathic medical care. This office does not bill, accept or participate in insurance programs. All services are due and payable on the day they are rendered.

I have read and I understand the above.

SIGNED_________________________________Date_______________

I understand that Dr. Myatt's consultations are accurate and complete to the best of her ability, but that no absolute claims are made to the correctness of the information therein. If I elect to follow Dr. Myatt's recommendations, I do so at my own risk and discretion, Again, this health consultation is not meant to replace the care of my primary medical physician.

I have read and I understand the above.

SIGNED_________________________________Date_______________

CANCELLATION POLICY: We reserve the right to charge for appointments cancelled or broken without 24 hours advanced notice.

I have read and I understand the above.

SIGNED_________________________________Date_______________

Help Yourself to Health!
with

Dana Myatt, N.M.D.

Family Practice, Natural Medicine

2005 Dr. Myatt's Wellness Club