Informed Consent for Treatment

Please fill-up the form below:

Notice of Services Offered

I request the services and medical expertise as offered by Dr. Mendoza and her staff personnel. I understand that Dr. Mendoza is a Naturopathic Physician that is licensed and Board certified in the state of Arizona. She also holds a Fellowship in Advanced Fellowship in Anti-Aging Metabolic, and Functional Medicine (FAAMFM). This includes advanced training in Anti-Aging Medicine, Functional Medicine and Cancer treatments.

I understand that the advice, diagnostic techniques and treatments that are included in Dr. Mendoza’s treatment plan are based on the acceptable “Naturopathic standards of care” and her knowledge based on levels of higher learning.

I understand that when possible, Dr. Mendoza would like to prevent disease rather than treat it and that her goal is to help me achieve my personal state of optimum health. Dr. Mendoza is an expert at interpreting laboratory results, patient histories, and physical exam findings. She can often identify the subtle signs of imbalance for before they become a diagnosable disease. Therefore, her interpretation of my laboratory work may differ from that of my other physicians who are using standard laboratory reference ranges to determine whether or not I have a nameable “disease”.

Signature

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PRIMARY CARE PHYSICIAN

1. Dr. Mendoza is a Primary Care Physician. She does practice primary care medicine and she will act as your primary care physician. If you already have a primary physician, then she will be in contact with your current physician to coordinate care.

2. Insurance deosn't cover the medical care provided by Sholo Healing Center. (Initials)

3. There must be communication between Dr. Mendoza and other healthcare provider. (Initials)

4. Dr. Mendoza is not affiliated with any hospital and does not do any admissions associated with hospital care. (Initials)

5. It is my responsibility to inform Dr. Mendoza ifI recieve any form of medical care or advice from any other primary care and/or medical practitioner. (Initials)

6. It is my responsibility to inform Dr. Mendoza of any diagnoses or treatments I recieve from any other primary care and/or medical practitioners. (Initials)

7. Dr. Mendoza is merely assisting my body's innate ability to heal itself. I am primarily the person responsible for my health and the outcome I recieve. (Initials)

Financial Policies

Sholo Healing Center is a cash pay clinic, completely outside of the insurance system. This is what allows Dr. Mendoza to adequately provide for her patients to ensure that healing is able to take place. To ensure that patients are provided with personalized care medicine, which goes above and beyond the highest reaches of the standardized care of insurance coverages. Sholo Healing Center does not submit insurance claims, collect from, negotiate with or respond to requests for information from any insurance company.

Laboratory Testing

Dr. Mendoza has negotiated with a testing lab for special self-pay prices for our patients. This is a very affordable option for cost saving self-pay laboratory testing.

I Agree that I am financially responsible for all charges incurred for office visits, treatments, medications or other services received at the time of service. PAYMENT IS DUE IN FULL AT THE TIME OF SERVICE. The charges of the office visit is determined by the time spent in consultation with Dr. Mendoza, the complexity of the case presented, additionally; the case may require additional research as well as consultation with other physicians or specialists. The initial office visit is $450 and will be one hour to 1 ½ hours in length.

Missed Appointments

I understand that Dr. Mendoza will set aside 1 ½ hours of her time for each new patient visit. There will be a $100 charge if I do not show up for my new patient visit or communicate your inability to go to your appointed time. Any other appointment time it is a $65 charge if I have not notified the Sholo Healing Center within 24 hours in advance of the appointment time.

Signature of the Patient or Responsible Party

Clear

Patients Name

Date

CONFIDENTIAL PATIENT INFORMATION

Patient name *

Date of birth *

Gender *

Age *

Height (cm) *

Weight *

Address *

City

State

Primary Phone Number *

Alternate Phone Number

Emergency Contact *

Emergency Contact's Phone Number *

Allergies to Medications *

Email *

Employer *

Occupation *

How did you hear about Sholo Healing Center?

Have you seen our website?

Yes

No (docdianna.com)

How committed are you to improving your health?

PHYSICIAN CONTACT INFORMATION

1. Primary Care Provider Name *

Phone *

Fax Number *

Date Last Seen *

Date of Next Appointment *

2. Specialist Name and Medical Specialty *

Phone *

Fax Number 2 *

Please List Your Health Concerns In Order of Importance

1. Health Concern

When did it start?

Types of Treatment

Diagnosis

2. Health Concern

When did it start?

Types of Treatment

Diagnosis

3. Health Concern

When did it start?

Types of Treatment

Diagnosis

Have you had or been diagnosed with any allergy (ies) to medications, Supplement or food?

Yes

What type of reactions did you have?

What medications and supplements are you taking?

1. Medication and Supplement

Name
Dosage/Frequency
Reasons for taking

2. Medication and Supplement

Name
Dosage/Frequency
Reason for taking

3. Medication and Supplement

Name
Dosage/Frequency
Reasons for taking

4. Medication and Supplement

Name
Dosage/Frequency
Reasons for taking

5. Medication and Supplement

Name
Dosage/Frequency
Reasons for taking

6. Medication and Supplement

Name
Dosage/Frequency
Reasons for taking

To add more, please write out a separate sheet including all of the above information.

SOCIAL HISTORY/LIFESTYLE QUESTIONS

Have you ever been physically or emotionally abused?

Yes

If yes, by whom?

How old were you?

Work

What is/was your occupation? *

Do you currently work?

How many hours?

How stressful is your job?

Family

Marital Status *

Married

Divorced

Single

Spouse Occupation

Hobbies

Diet

How much water do you drink in a day? (ml) *

Soda

Organic meat

Coffee

Alcohol

Tobacco

Snuff

Do you have any symptoms of when you eat food? "Like it sits like a rock in my stomach" or I do not eat a certain food anymore because it causes acid reflux, etc.

What are the types of oils you cook with?

Describe Your Typical Meals:

Breakfast

Lunch

Dinner

Snacks

Exercise

Describe your schedule and types of exercise.

PLEASE ANSWER THE FOLLOWING QUESTIONS BY CHECKING THE PAST OR NOW BOX IF APPLICABLE

Energy Drink

Recreational Drugs

Pain Medicine

Antidepressant Medication

Sleep Medication

Anti-anxiety Medication

Laxatives

Steroids (Prednisone, Dexamethasone, body building etc.)

Birth Control Medication

REVIEW OF SYMPTOMS

What was your weight a year ago. (lbs)

What was your maximum weight. (lbs)

What do you feel is your ideal weight. (lbs)

SLEEP

How many hours do you sleep on a typical night?

Do you take anything (medications) to help you sleep?

How rested are you when you get up in the morning?

Do you go back to sleep right away?

Do you get up to go to the bathroom at night?

FAMILY HISTORY

Auto-immunity

Father
Mother
Siblings
Grandparents

Arthritis

Father
Mother
Siblings
Grandparents

Cancer

Father
Mother
Siblings
Grandparents

Diabetes

Father
Mother
Siblings
Grandparents

High Blood Pressure

Father
Mother
Siblings
Grandparents

Osteoporosis

Father
Mother
Siblings
Grandparents

Mental Illness

Father
Mother
Siblings
Grandparents

Thyroid Disorder

Father
Mother
Siblings
Grandparents

FEMALE SPECIFIC QUESTION

At what age did you experience your first period?

How often does your period occur?

When was your last Pap smear?

Have you had any abnormal Pap smears?

How many live births have you had?

How many times have you been pregnant?

Did you give birth normally or by cesarean?

When did you have your last breast exam?

Have you ever had a bone density scan done?

Have you ever been diagnosed with any type of cancer?

Have you ever had any breast surgeries?

Have you ever had a biopsy?

Mastectomy?

Do you have implants?

Toxic Exposure

1. Did you grow up in an area that is considered toxic?

2. Do you live or have you ever lived in an area of a refinery, polluted area, or a home with leaded paint?

3. Have you ever had any health problems, that just never seem to go away?

4. Do you feel you are particularly sensitive to perfumes, vapors or gas?

5. Do you use pesticides or other household chemicals in your home?

Male Specific Questions

1. When was the date of your last prostate exam?

2. Have you ever been diagnosed with prostate cancer?

3. Have you ever had an abnormal prostate exam?

4. Have you ever had a prostate biopsy?

5. How many times do you get up to urinate at night?

6. Is your urine flow strong?

7. Do you have a decrease in your erections?

8. Can you get and maintain an erection?

9. Do have a decrease in your sexual desire (libido)?

10. Do you have a decrease in your overall muscle tone?

11. Do you have any blood in your urine?

12. Have you been diagnosed with any sexually transmitted disease?

13. Do you have irritability or depression? Describe

DIET DIARY INSTRUCTIONS

1. It is important for Dr. Mendoza to evaluate everything. It is important for you to chart what you consume in your daily diet for one week. This should include all food, drinks, and snacks. She asks that you not alter what you eat or drink, as this is a non-judgmental area. It is very important to ascertain what may be at the root of any problems that you may be having.

2. On all foods, please list ingredients and quantity. Please include brand names for all packaged and processed foods. All processed foods are those that you will find in a package or a box. They are made by man. They will contain more than one ingredient, such as hamburger Helper.

3. If you eat out at a restaurant, please give me the name of the restaurant and describe your meal. Snacks, anything candy bars, etc.

4. All non-water drinks. How many ounces and also how many carbohydrates and sugars are included.

Office Policies and Procedures New Patient Appointments

Your initial visit is a very detailed consultation with Dr. Mendoza that will last for approximately one hour, however, depending on your case, it may go up to 1 ½ hours. She will take a detailed medical history, conduct a complete physical exam, and will order whatever laboratory work she deems necessary.

Additionally, she will listen to your whole story with a special emphasis on what you want to accomplish from your treatment and what type of changes you are willing to make. It is important to be completely honest with Dr. Mendoza, please don’t leave out information, i.e. like you are seeing another provider and they are providing some other type of care.

During your second visit, you and the doctor will discuss your laboratory results, her assessment of your case, and your personalized written treatment plan. Please make sure to ask all of your questions and voice any concerns you may have about your treatment plan during this appointment.

Follow up appointments

1. Your first follow up appointment is usually scheduled 2-4 weeks after starting your treatment. Most cases are complex and may initially require frequent follow up. Follow up appointments are usually scheduled every 4-6 weeks for the first 3-6 months of treatment. The caveat to this is if you are scheduled for Intravenous Therapy (IV), this may be weekly or more frequently as Dr. Mendoza deems is necessary for your case.

2. Please arrive 15 minutes before your scheduled appointment. We ask that all of our patients use standard Covid -19 precautions of wearing a mask and washing your hands on arrival.

3. No results will be discussed over the phone unless previously arranged with Dr. Mendoza. We have a great number of people who travel from other states and so this is something we will arrange in advance.

4. As a courtesy to patients who are not able to come in to the office in person we offer phone appointments that are billed at the same rate as a regular office visit. (Initials)

5. Please be sure to call our office with any questions. a. Phone calls pertaining directly to your recent visit, and which require 1-2 minutes will be answered. b. Phone calls will be answered as soon as possible, within 24 hours or the next business day. c. More complex discussions will require a follow up appointment with the doctor. If needed, a phone appointment will be scheduled and will be billed at the same rate as an office visit.

Prescription refills

1. During your office visit, the doctor will give you prescriptions with the appropriate number of refills to last until your next follow up visit.

2. Please make sure you have all of the prescriptions you need before you leave the office.

3. An office visit is required at minimum every 6 months, or as specified by the doctor to evaluate your care, order labs, and approve additional refills.

4. Failure to make and keep scheduled appointments will make it difficult to continue your care and will result in having refills denied.

5. To avoid waiting, please call before picking up refills from our dispensary.

Nutritional supplements

1. Nutritional supplements are an important part of your treatment. Please continue to take them as prescribed unless you are directed to discontinue or change dosage by the doctor.

2. Please be aware that since nutritional supplements are not regulated and standardized in the same way as prescription medications, different brands are not equivalent. It is important that you let us know in advance of what you will need to have refilled. Many of the supplements are specialty medications and need to be ordered, so we do not keep all of them in the office.

3. Dr. Mendoza spends a great deal of time researching nutritional supplements to determine which ones will be best for her patients. For best results take the exact supplements that Dr. Mendoza has prescribed for you, at the doses specified in your treatment plan.(Initials)

Lab Procedures and Results

1. It is imperative that all necessary laboratory work be completed on time so that your results are available for discussion during your next scheduled appointment.

2. Our office staff is not authorized to discuss your lab results with you over the phone

3. If you elect to have your primary care physician order your laboratory results so that it can be billed to insurance, it is your responsibility to make sure that the correct labs are ordered and that we receive the results at least 48 hours before your appointment.

4. If you have labs ordered by your PCP it will be important that you make sure that the correct lab test codes be included on the order and that you get the labs run through the lab.

Fasting and Bloodwork

1. Fasting bloodwork requires that you have nothing by mouth, other than water after 10pm the night before your blood draw appointment.

2. Please drink plenty of water prior to your blood draw

3. Please ask about how to take your medications the morning of your draw.

Medical Records Release

1. A signed release is required before any information in your chart can be mailed or faxed to you, another physician, or a third party.

2. Records are sent to your physician at no charge.

3. Copies of your labs are given to you at your follow up visit. Additional copies will be billed at $1 per page. I have read and understand the office policies

Patient or Guardian

Signature

Clear

Date

Patient Name

Office Personnel Signature

Clear

OUR ADDRESS AND HOURS ARE:

203 S Candy Lane, Suite 10 C, Cottonwood, AZ 86326 Phone: 928-202-4999 Fax: 928-202-4144

The hours are 9:00 AM to 4:00 PM Tuesday through Friday.

Refund Policy

There are no refunds or returns for our services except where Company (Sholo Healing Center) becomes legally unable to provide services. There are no refunds on any products and/or laboratory services, supplements, or services rendered. We are reasonable people and expect to be paid for work that we complete but we also understand that circumstances can change and will do our best to work with you to resolve any performance issues. Please review the terms of your agreement regarding termination provisions.(Initials)

Please fill-up the form below:

Notice of Services Offered

Signature

Clear

PRIMARY CARE PHYSICIAN

2. Insurance deosn't cover the medical care provided by Sholo Healing Center. (Initials)

3. There must be communication between Dr. Mendoza and other healthcare provider. (Initials)

4. Dr. Mendoza is not affiliated with any hospital and does not do any admissions associated with hospital care. (Initials)

5. It is my responsibility to inform Dr. Mendoza ifI recieve any form of medical care or advice from any other primary care and/or medical practitioner. (Initials)

6. It is my responsibility to inform Dr. Mendoza of any diagnoses or treatments I recieve from any other primary care and/or medical practitioners. (Initials)

7. Dr. Mendoza is merely assisting my body's innate ability to heal itself. I am primarily the person responsible for my health and the outcome I recieve. (Initials)

Financial Policies

Laboratory Testing

Dr. Mendoza has negotiated with a testing lab for special self-pay prices for our patients. This is a very affordable option for cost saving self-pay laboratory testing.

Missed Appointments

Signature of the Patient or Responsible Party

Clear

Patients Name

Date

CONFIDENTIAL PATIENT INFORMATION

Patient name *

Date of birth *

Gender *

Age *

Height (cm) *

Weight *

Address *

City

State

Primary Phone Number *

Alternate Phone Number

Emergency Contact *

Emergency Contact's Phone Number *

Allergies to Medications *

Email *

Employer *

Occupation *

How did you hear about Sholo Healing Center?

Have you seen our website?

Yes

No (docdianna.com)

How committed are you to improving your health?

PHYSICIAN CONTACT INFORMATION

1. Primary Care Provider Name *

Phone *

Fax Number *

Date Last Seen *

Date of Next Appointment *

2. Specialist Name and Medical Specialty *

Phone *

Fax Number 2 *

Please List Your Health Concerns In Order of Importance

1. Health Concern

When did it start?

Types of Treatment

Diagnosis

2. Health Concern

When did it start?

Types of Treatment

Diagnosis

3. Health Concern

When did it start?

Types of Treatment

Diagnosis

Have you had or been diagnosed with any allergy (ies) to medications, Supplement or food?

Yes

What type of reactions did you have?

What medications and supplements are you taking?

1. Medication and Supplement

Name
Dosage/Frequency
Reasons for taking

2. Medication and Supplement

Name
Dosage/Frequency
Reason for taking

3. Medication and Supplement

Name
Dosage/Frequency
Reasons for taking

4. Medication and Supplement

Name
Dosage/Frequency
Reasons for taking

5. Medication and Supplement

Name
Dosage/Frequency
Reasons for taking

6. Medication and Supplement

Name
Dosage/Frequency
Reasons for taking

To add more, please write out a separate sheet including all of the above information.

SOCIAL HISTORY/LIFESTYLE QUESTIONS

Have you ever been physically or emotionally abused?

Yes

If yes, by whom?

How old were you?

Work

What is/was your occupation? *

Do you currently work?

How many hours?

How stressful is your job?

Family

Marital Status *

Married

Divorced

Single

Spouse Occupation

Hobbies

Diet

How much water do you drink in a day? (ml) *

Soda

Organic meat

Coffee

Alcohol

Tobacco

Snuff

Do you have any symptoms of when you eat food? "Like it sits like a rock in my stomach" or I do not eat a certain food anymore because it causes acid reflux, etc.

What are the types of oils you cook with?

Describe Your Typical Meals:

Breakfast

Lunch

Dinner

Snacks

Exercise

Describe your schedule and types of exercise.

PLEASE ANSWER THE FOLLOWING QUESTIONS BY CHECKING THE PAST OR NOW BOX IF APPLICABLE

Energy Drink

Recreational Drugs

Pain Medicine

Antidepressant Medication

Sleep Medication

Anti-anxiety Medication

Laxatives

Steroids (Prednisone, Dexamethasone, body building etc.)

Birth Control Medication

REVIEW OF SYMPTOMS

What was your weight a year ago. (lbs)

What was your maximum weight. (lbs)

What do you feel is your ideal weight. (lbs)

SLEEP

How many hours do you sleep on a typical night?

Do you take anything (medications) to help you sleep?

How rested are you when you get up in the morning?

Do you go back to sleep right away?

Do you get up to go to the bathroom at night?

FAMILY HISTORY

Auto-immunity

Father
Mother
Siblings
Grandparents

Arthritis

Father
Mother
Siblings
Grandparents

Cancer

Father
Mother
Siblings
Grandparents

Diabetes

Father
Mother
Siblings
Grandparents

High Blood Pressure

Father
Mother
Siblings
Grandparents

Osteoporosis

Father
Mother
Siblings
Grandparents

Mental Illness

Father
Mother
Siblings
Grandparents

Thyroid Disorder

Father
Mother
Siblings
Grandparents

FEMALE SPECIFIC QUESTION

At what age did you experience your first period?

How often does your period occur?

When was your last Pap smear?

Have you had any abnormal Pap smears?

How many live births have you had?

How many times have you been pregnant?

Did you give birth normally or by cesarean?

When did you have your last breast exam?

Have you ever had a bone density scan done?

Have you ever been diagnosed with any type of cancer?

Have you ever had any breast surgeries?

Have you ever had a biopsy?

Mastectomy?

Do you have implants?

Toxic Exposure

1. Did you grow up in an area that is considered toxic?

2. Do you live or have you ever lived in an area of a refinery, polluted area, or a home with leaded paint?

3. Have you ever had any health problems, that just never seem to go away?

4. Do you feel you are particularly sensitive to perfumes, vapors or gas?

5. Do you use pesticides or other household chemicals in your home?

Male Specific Questions

1. When was the date of your last prostate exam?

2. Have you ever been diagnosed with prostate cancer?

3. Have you ever had an abnormal prostate exam?

4. Have you ever had a prostate biopsy?

5. How many times do you get up to urinate at night?

6. Is your urine flow strong?

7. Do you have a decrease in your erections?

8. Can you get and maintain an erection?

9. Do have a decrease in your sexual desire (libido)?

10. Do you have a decrease in your overall muscle tone?

11. Do you have any blood in your urine?

12. Have you been diagnosed with any sexually transmitted disease?

13. Do you have irritability or depression? Describe

DIET DIARY INSTRUCTIONS

3. If you eat out at a restaurant, please give me the name of the restaurant and describe your meal. Snacks, anything candy bars, etc.

4. All non-water drinks. How many ounces and also how many carbohydrates and sugars are included.

Office Policies and Procedures New Patient Appointments

Follow up appointments

2. Please arrive 15 minutes before your scheduled appointment. We ask that all of our patients use standard Covid -19 precautions of wearing a mask and washing your hands on arrival.

4. As a courtesy to patients who are not able to come in to the office in person we offer phone appointments that are billed at the same rate as a regular office visit. (Initials)

Prescription refills

1. During your office visit, the doctor will give you prescriptions with the appropriate number of refills to last until your next follow up visit.

2. Please make sure you have all of the prescriptions you need before you leave the office.

3. An office visit is required at minimum every 6 months, or as specified by the doctor to evaluate your care, order labs, and approve additional refills.

4. Failure to make and keep scheduled appointments will make it difficult to continue your care and will result in having refills denied.

5. To avoid waiting, please call before picking up refills from our dispensary.

Nutritional supplements

1. Nutritional supplements are an important part of your treatment. Please continue to take them as prescribed unless you are directed to discontinue or change dosage by the doctor.

Lab Procedures and Results

1. It is imperative that all necessary laboratory work be completed on time so that your results are available for discussion during your next scheduled appointment.

2. Our office staff is not authorized to discuss your lab results with you over the phone

4. If you have labs ordered by your PCP it will be important that you make sure that the correct lab test codes be included on the order and that you get the labs run through the lab.

Fasting and Bloodwork

1. Fasting bloodwork requires that you have nothing by mouth, other than water after 10pm the night before your blood draw appointment.

2. Please drink plenty of water prior to your blood draw

3. Please ask about how to take your medications the morning of your draw.

Medical Records Release

1. A signed release is required before any information in your chart can be mailed or faxed to you, another physician, or a third party.

2. Records are sent to your physician at no charge.

3. Copies of your labs are given to you at your follow up visit. Additional copies will be billed at $1 per page. I have read and understand the office policies

Patient or Guardian

Signature

Clear

Date

Patient Name

Office Personnel Signature

Clear

OUR ADDRESS AND HOURS ARE:

203 S Candy Lane, Suite 10 C, Cottonwood, AZ 86326 Phone: 928-202-4999 Fax: 928-202-4144

The hours are 9:00 AM to 4:00 PM Tuesday through Friday.

Refund Policy