CONSULTATION REQUEST REVIEW SHEET

INTRUCTIONS FOR THERMAL IMAGING CLIENTS REQUESTING MEDICAL CONSULATION WITH DR. PITTMAN If you are interested in making an appointment, please be sure you have reviewed all information on our website www.carolinacenter.com under “Thermal Imaging Consultation”. This information is also on the website www.carolinathermascan.com under “New Clients”. You are requesting a 15 minute consultation with Dr. Pittman following your thermascan to review your medical history so as to provide clinical correlation for the findings of the scan. This will include recommendations for further evaluation if indicated, nutritional supplements that may be helpful based on these findings, and plans for ongoing monitoring. Thermography Services Offered – Please check one: ____ Breast Screening: $235 for scan and $152 for consultation. ____ Abdomen and Lower Back: $140 for scan and $152 for consultation ____ Head and Neck: $180 for scan and $152 for consultation ____ Chest and Lungs (Men): $205 for scan and $152 for consultation

• Please complete the specific Carolina Thermascan Medical History Form for the body part you wish to have scanned.

• Complete and sign the Patient Registration/Insurance Authorization Form • Provide us a copy of your insurance card, both front and back and a copy of your Driver’s License or other

official identification which is required by the US Patriot Act. Failure to provide these documents will delay scheduling your appointment.

• Please come prepared with copies of any pertinent medical records and recent laboratory results related to your reason for the thermascan.

• We require a non-refundable $50 deposit to process your initial paperwork. The balance of $102 for the Consultation will be due at the time your visit is scheduled. This balance can be refunded up to 2 weeks prior to your actual office visit. The $50 deposit is not refundable. Send a check payable to The Carolina Center or complete the following if you wish to make a credit / debit card payment.

____Visa ____MasterCard ____American Express

Account #: ______________________________ Expiration: ____/____

Cardholder Name: ____________________________________________

Cardholder Signature: _________________________________________

Please be aware of our No Perfume-Scented Toiletries Policy and refrain from wearing any perfumes, colognes, and other scented toiletries and personal items while at the clinic.

I have read the information on The Carolina Center website under “Thermal Imaging Consultations” and understand these procedures. I am requesting this brief consultation in conjunction with the above requested thermascan and understand that this encounter will be limited to the specific issue for which I have requested this procedure. I understand that the $152 fee for this consultation does not include the fee for the actual thermal imaging. I understand that this consultation is not meant to replace a more comprehensive office visit to address other issues. I understand that if any other issues arise for which more extensive evaluation or treatment needs to be provided, it may be necessary to schedule a longer visit. I am requesting to become a patient of the Carolina Center for this limited encounter and understand it is highly recommended that I attend the Introduction to the Carolina Center Group Orientation. I understand that I will not be undergoing an evaluation at this Orientation. I understand that the $50 deposit is non-refundable.

________________________________________________________ __________ Signature Date Please check to be sure you have ALL the above items completed and return this form to The Carolina Center for Integrative Medicine, P.A., New Patient Coordinator, 4505 Fair Meadow Lane, Suite 111, Raleigh, NC 27607 or E-mail to: angel@carolinacenter.com.

ConsultationRequestReviewSheet1-8-18

Confidential Questionnaire

Breast Health Screening

First Name ______________________ Middle Initial_____ Last Name _______________________ Date of Birth ____/___/______ Age ______ Address City State Zip Home Phone# _______________ Work Phone#_________________ Cell Phone#_____________ Email Please tell us how you heard about Carolina Thermascan__________________________________ Location of scan and affiliation (please check) __ Raleigh – Patient of the Carolina Center for Integrative Medicine __ Raleigh – Non-Patient __ Raleigh – Patient of Vaughan Integrative Medicine of Greensboro __ Wilmington – Restore Health & Wellness Center __ Wilmington – ChiroCynergy If you are a patient at any of any providers at the above locations, we will provide a copy of your report to that practitioner. Name of Provider: _____________________________________ Were you referred by another health care practitioner? Yes____ No ____ If so, we will send a copy of your scan and report to that practitioner. Please provide: ____________________________________________________________________________________________________________________________________________________________________________________ CURRENT MEDICATIONS AND SUPPLEMENTS: Medications: _______________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________ Allergies: _________________________________________________________________________________ Supplements: ______________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________

What is your specific concern and reason for obtaining this breast screening scan?

Yes No 1. Have you recently had any of these breast symptoms? (mark only if “yes”) __ __ LT RT Pain/Tenderness ___ ___ Lumps ___ ___ Change in breast size ___ ___ Areas of skin changes thickening or dimpling ___ ___ Excretions or changes of the nipple ___ ___

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NOTES: Indicate by letter on the diagram the region of the breasts if affected by the following: A Mass B Thickening C Discharge D Nipple Change E Skin Change F Area of Pain G Burning H Tender I Dull Ache J Sharp Pain

2. Are any of the above symptoms cycle related? Yes____ No______ 3. Are you still having your periods? Yes____ No______ 4. Have you had a surgical hysterectomy? Yes____ No______ If yes, date Complete __ Partial ___ Reason for hysterectomy? ○ Excess bleeding ○ Endometriosis ○ Fibroid cysts ○ Cancer ○ Other 5. Has anyone in your family ever been treated for breast cancer? Yes____ No______ If yes, note age and survival

Mother_____Sister_____Daughter_____ Maternal Grandmother____Maternal Aunt___ Maternal cousin___Paternal Grandmother____Paternal aunt____Paternal cousin____

6. Have you ever had a biopsy? Yes ____ No____ Location: _______ Date:_______ Outcome:_______ 7. Have you ever been diagnosed with breast cancer? Yes____ No______ If yes, date: Month: ______ Year: _________ Location: ______ Date:_______ Outcome:_______ Cancer type ○ Local ○ Metastatic ○ Lymph node involvement Left breast ○ Inner ○ Outer ○ Nipple Right breast ○ Inner ○ Outer ○ Nipple Treatment ○ Surgery ○ Chemo ○ Radiation ○ None

Lumpectomy: Yes ______ No _______ R________ L ________ Year of Surgery_________ Mastectomy: Yes ______ No _______ R________ L ________ Year of Surgery_________ Breast Reconstruction: Yes ______ No________R________ L ________ Year of Surgery_________ Radiation to the Breast: Yes ______ No_______ R________ L ________ Year of Treatment_______ Chemotherapy: Yes ______ No_______ R________ L ________ Year of Treatment_______ Breast Augmentation: Yes ______ No________R________ L ________ Year of Surgery ________ Any palpable mass now? Yes ______ No________R________ L ________ Any discharge, inversion or change in nipples? Yes ______ No________R________ L ________

8. Have you ever been diagnosed with any other breast disease? Yes____ No______ If yes: Cysts/fibrocystic ___ Fibro Adenoma ___ Mastitis/inflammatory breast disease ___

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9. Have you had any cosmetic breast surgery or implants? Yes____ No______ If yes, date ○ Silicone ○ Saline Experience: ○ Problems ○ No problems 10. Have you ever had any biopsies or any other surgeries to your breasts Yes____ No______ If yes, date Left breast ○ Inner ○ Outer ○ Nipple Right breast ○ Inner ○ Outer ○ Nipple Results ○ Negative ○ Positive ○ Calcifications 11. Have you ever taken contraceptive pills for more than one year? Yes____ No______ If yes, ○ Currently ○ Less than 5 years ○ More than 5 years 12. Have you had pharmaceutical hormone replacement therapy (HRT)? Yes____ No______ If yes, ○ Currently ○ Less than 5 years ○ More than 5 years 13. Do you have an annual physical examination by a doctor? Yes____ No______ 14. Do you perform a monthly breast self-exam? Yes____ No______ 15. Have you ever smoked? Yes____ No______ 16. Have you ever been diagnosed with diabetes? Yes____ No______ 17. Have you had a mammogram? Yes____ No____ Results: Normal _____ Abnormal____ Suspicious_______ 18. Age at first mammogram _______ 19. Date of last mammogram ______ Were you called back for a repeat? Yes____ No____ 20. Have you had breast ultrasound? Yes____ No____ If yes…Date:____/____ Left ___ Right___ Results: Negative___ Positive ___ 21. Have you had breast MRI? Yes____ No____ If yes…Date:____/____ Left ___ Right___ Results: Negative___ Positive ___ 22. Have you ever undergoing Infrared Thermal Breast Imaging: Yes____ No____ If yes…Date:____/____ Left ___ Right___ Results: Negative___ Positive ___ Procedure: You will be imaged with a state-of-the art infrared camera in comfortable and controlled surroundings. Your thermal imaging baseline reports will provide information about current and future conditions only and does not diagnose breast disease. Thermal imaging should be correlated with other medical investigative methods to better direct definitive testing for diagnosis and treatment. It does not replace any other breast examination. Disclosure: I understand that the report generated from my images is intended for use by a trained health care provider to assist in evaluation and treatment. I further understand that the report is not intended to be used by myself for self-evaluation or self-diagnosis. I understand that the report will not tell me whether I have any illness, diseases, or other conditions, but will be an analysis of the images with respect only to the thermographic findings discussed in the report. By signing below, I certify that I have read and understand the statement above and consent to the examination. Client Signature Today’s Date

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THE CAROLINA CENTER FOR INTEGRATIVE MEDICINE, P.A. - PATIENT REGISTRATION/INSURANCE FORM

Patient’s Legal Name: (First, Middle Initial, Last): Social Security #:

Patient Address: County:

Home #: Cell #:

Sex M or F Birth date: Email address:

Marital Status: Single Married Divorced Widowed Domestic Partnership

Spouse’s Name (if applicable): # of household members: Ethnicity:

Person responsible for payment:

Patient’s Employer and Occupation:

Employer Address: Work #: Ext:

Primary Care Physician Name: Phone #:

DO YOU HAVE HEALTH INSURANCE? YES NO (Circle one) - If you answered YES, please provide a copy of your insurance card and complete the following:

Primary Insurance: Subscriber’s Name:

Sex of Subscriber: M F Birth date of Subscriber: Social Security #:

Relationship to Patient: Policy #: Group #:

Secondary Insurance: Subscriber’s Name:

Sex of Subscriber: M F Birth date of Subscriber: Social Security #:

Relationship to Patient: Policy #: Group #:

Emergency Contact: Name: Phone #:_

Please tell us how you heard about our practice (circle one or more): Yellow Pages Newspaper Website Internet Family/Friend

Other:

Who can we thank for referring you to our practice?

Financial Obligation Statement

The services you are electing to receive imply a financial responsibility on your part. This responsibility obligates you to ensure payment in full of any and all charges incurred. As a courtesy, we will verify any insurance coverage and bill your insurance carrier on your behalf with the exception of Medicare, Medicaid, and Blue Cross Blue Shield; however, you are ultimately responsible for the payment of your bill. Payment for all office visits, procedures and other services is expected at the time the service is provided. Payment is also due immediately upon receipt of any bill presented to cover any deductible or coinsurance as determined by your contract with your insurance carrier. Many insurance companies have additional stipulations that may affect your coverage. You are responsible for any amount not covered by your insurer. If your insurance carrier denies any part of your claim you will obligated for your account balance in full. I authorize my insurer to pay any benefits directly to Carolina Center for Integrative Medicine. I also agree to pay the Carolina Center the full and entire amount of all bills incurred by me within 30 days of treatment or upon receipt of any amount due after payment has been made by my insurance carrier. I understand that I will be assessed interest of 15% on any unpaid balance after 30 days and this interest will continue to accrue until payment is made in full. I have read the above policy regarding my financial responsibility to the Carolina Center for providing services to me. I certify that the information provided is, to the best of my knowledge, true and accurate.

Patient/Guardian Signature: Date:

10/2013

The Carolina Center for Integrative Medicine, P.A. John C. Pittman, M.D.

www.carolinacenter.com.

HIPPA Privacy Authorization Form

PATIENT NAME: ____________________________________________________________________

DOB: ___ /___ /____

STREET ADDRESS: ___________________________________________________________________

CITY, STATE, ZIP: ____________________________________________________________________

I, _________________________________, hereby authorize Carolina Center for Integrative Medicine and/or any medical facility to release any and all medical information and test results that pertain to me, to the following person(s).

Name:_____________________________ Phone #: (____)______-_________ Relationship to pt. ______________

Name:_____________________________ Phone #: (____)______-_________ Relationship to pt. ______________

Name:_____________________________ Phone #: (____)______-_________ Relationship to pt. ______________

I authorize Carolina Center for Integrative Medicine or the medical practice to contact the individual(s) listed above to convey any pertinent information to me, in the event that I am unable to be reached by the practice.

I understand that I may revoke/cancel this authorization by notifying The Carolina Center in writing of my intent to revoke authorization or change the name(s) of the individuals to whom information is to be released.

_____________________________________ _____________________________ Signature of Patient Date

_____________________________________ _____________________________ Signature of Guardian (if applicable) Date

_____________________________________ ____________________________ Signature of Witness (Office Staff ONLY) Date

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The Carolina Center for Integrative Medicine, P.A. John C. Pittman, M.D. Jill C. Vanarthos, P.A.-C.

www.carolinacenter.com. 4505 Fair Meadow Lane #111 Telephone (919) 571-4391 Raleigh, NC 27607 Fax (919) 571-8968

THE CAROLINA CENTER FOR INTEGRATIVE MEDICINE

POLICIES FOR THERMAL IMAGING PATIENTS

No Perfume or Scented Toiletries in the Clinic

At one time perfumes and colognes were actually made from flower essences, natural products that actually had health-promoting benefits. Today, virtually all scented toiletries are made with petroleum products, some containing as many as 5000 synthetic compounds. Individuals whose internal systems of detoxification are functioning poorly may experience severe reactions when exposed to such toxins. In other cases the reactions are significant but more subtle and thus harder to discern.

Many individuals who come to the Center, including our staff, have problems with chemical sensitivities and become violently ill when exposed to chemicals, perfume, gasoline and other fumes. We require that all patients refrain from the use of perfume or other scented toiletries while at the Center. This rule also applies to those individuals who may have scents on their clothing, even if they did not actively apply anything to their body prior to arrival. If any of our staff detects the presence of fragrances, we will ask that individual to wash off the offending scent. If, after this effort, the scent is still deemed to be overpowering, we will ask you to leave. Under these circumstances, because we have notified all patients of this policy, you will be assessed a cancellation fee. We urge all patients to use commonsense (not scents!)—please respect and abide by this policy.

Purchasing Nutritional Supplements

As a convenience to our patients, our associate business, Total Health Nutrition Center, Inc., (THNC) provides many of your recommended nutritional and herbal supplements for purchase, even though it may be possible to purchase these supplements at local pharmacies, health food stores, grocery stores, and specialty supplement stores. The supplements carried by THNC have been chosen based on quality and formulation. To the best of our knowledge, these supplements come from reputable companies, and many of these companies provide only pharmaceutical grade products and distribute only to physicians.

In making their selections from over 200 companies, THNC gives the highest priority to ingredient quality, manufacturing excellence, and quality control. In most cases, the selected products have scored at the highest levels when evaluated objectively by independent, third-party laboratory testing for nutrient content, purity, dissolvability, and bioavaibility (absorption). At the same time, keen attention is devoted to getting the best prices for specific products that are being compared. (See the Carolina Center website for more details on how we interact with THNC.)

Despite all our efforts to adhere to these high standards, however, we can offer no guarantees as to the effectiveness of these products. Moreover, the North Carolina Medical Board has a policy regarding the sale of goods from physician offices, and Dr. Pittman complies with this policy by informing you that you may purchase supplements at other places and by disclosing our financial interest in the sale of supplements. THNC and Dr. Pittman have a financial interest in the sale of supplements in that profit generated from these sales is used to cover the costs of providing this service. Again, however, we strive to provide reasonable pricing and, for the most part, we charge less than those offered by other sources or at other store locations.

Payment Due at Time of Service

Payments for initial office visits and thermography consultations are due in full at the time of scheduling. Payments for follow-up thermography consultations are due in full at the time of service unless other arrangements have been made in advance.

Health Insurance Coverage for Services at the Center

The Carolina Center does not contract with insurance companies, including Medicare/Medicaid/Tricare. Moreover, although many of our services have been covered by insurance in the past, we can provide no assurance or guarantee that you will receive insurance reimbursement for any of the charges at the Center. As a courtesy, these charges will be filed with your insurance company if it is determined that you have out-of-network benefits, and you will receive reimbursement from the Center when appropriate. The main exception is Blue Cross Blue Shield (BCBS), which will not reimburse for services, regardless of whether you have out-of-network benefit status. In addition, the Carolina Center will not provide BCBS any records for the purpose of insurance determination if requested by the insurance company or the patient. Finally, the Center has “opted out” of the Medicare program, and Medicare will not reimburse for any fees paid to the Center or the patient.

Your ability to receive insurance reimbursement for any of the charges at the Carolina Center will depend on the specific policies of your insurance carrier. With the exception of BCBS and Medicare, many insurance carriers are increasingly willing to provide coverage for integrative medicine, recognizing its emphasis on health promotion and disease prevention (which ultimately translates into lower health care costs over time). If you are among those millions of Americans who cannot afford health insurance, we will work with you, as much as possible, to accommodate your budgetary constraints, and we will plan strategically to minimize costs while hopefully meeting your treatment and health-related goals.

At the time of each office visit, our staff will determine if out-of-network benefits are available for each patient. If such benefits are available, we will file the charges on your behalf. A partial payment of 80% of the total bill is required at the time of service. Any payments received from your insurance company will first be applied to any balance due, after which you may receive a refund, be billed for a balance, or owe nothing.

Filing for Laboratory Testing

As noted above for those patients we determine have out-of-network coverage with carriers with whom we have had good experience with payment and the plan has a reasonable deductible that is likely to be met quickly, the Carolina Center will submit claims for all services rendered to the carrier in an attempt to receive payment. In the case of laboratory testing, the Carolina Center will file for these charges and not request payment in advance, other than whatever out-of-network deductible is still owed.

The Carolina Center can only estimate insurance payments based on past experience and communications with various insurance carriers. Based on these estimated calculations after receipt of the deductible from the patient and other fees and payment to the Carolina Center by the insurance carrier, it may be determined that the patient owes a balance if the insurance carrier considered certain tests to be non-covered. We will inform all patients of the maximum amount possibly owed in the event the insurance payment and payments prior to testing do not adequately cover costs of these tests.

Be aware that any payments made directly to the patient by the insurance company for the services filed by the Carolina Center is owed to the Carolina Center and must be paid immediately. The Carolina Center will apply any insurance payments reimbursed to remaining amounts due for non-reimbursed charges. If there is a credit from the insurance reimbursement, Carolina Center will credit the patients account for funds due. If there is a credit after these applications, this amount will be itemized and reimbursed within 30 days, unless one is on an ongoing treatment plan at the Center, in which case the Center will retain these funds to be applied to these services. Patients have the right to request these credited funds be reimbursed and upon written request, these will be provided within 30 days.

Cancellation Policy for New Patients

A non-refundable deposit of $50 is due upon receipt of the Consultation Request Review Sheet and other requested materials. The balance of $102 for the Consultation will be due at the time your visit is scheduled. The balance can be refunded up to two weeks prior to your actual Consultation. No refunds will be made if a cancellation request is received after this time period however patients will be allowed one opportunity to reschedule. If this rescheduled appointment is then cancelled again, the patient will not be allowed to reschedule any appointments and will forfeit all payments. Under these circumstances, the individual must reapply to be a new patient, submitting a new Patient Registration Form along with another $50 deposit. No credit will be given for any previous payments made. There will be no waivers of these fees for New Patients.

Cancellation Policy for Established Patients

Appointments for thermography consultations are typically made several weeks in advance; therefore, every effort should be made to keep this appointment as scheduled. We understand that there may be circumstances that require you to change a regularly scheduled office appointment; however, we require that you notify our office no less than 7 days in advance if you are unable to keep your appointment.

Please realize that our schedule is often booked many weeks in advance and there are many patients with equally serious health problems who are often on a waiting list for a cancellation. Your prompt notification will allow another patient the opportunity to take your appointment time. If you fail to give us 7 days advance notification for rescheduling/cancellation of a regularly scheduled office visit of any length, there will be a $50 fee charged. In addition, if you fail to give us 24 business hours advance notification of this change, the cancellation fee will be the full charge for the appointment which is $152. In some cases when patients repeatedly cancel, we may require them to make a non-refundable deposit for the full office visit charge to hold the next appointment.

Rescheduling Policy

If you cancel or are a no-show for a Thermography Consultation but reschedule the Consultation within the next 7 days to be seen within the next 21 days, the cancellation/no-show fee will be reduced by 50%. We understand that situations arise where a cancellation or no-show may be unavoidable, and therefore we will allow our patients to receive this discount up to two times. Please be aware that if you cancel again with less than a 7 day notice, or are a no-show for the rescheduled appointment, you will be subject to two fees. In this circumstance, you will owe the initial cancellation/no-show fee in full as well as the new cancellation or no-show fee which must be paid prior to being able to reschedule any further office visits or treatments at the Center. Upon receipt of this payment, you will be given one more opportunity to reschedule according to the above terms, but must pay a deposit of the full office visit charge to hold your rescheduled appointment.

ACKNOWLEDGEMENT OF POLICIES

By signing below, I acknowledge that I have read, understand, and accept the above Carolina Center policies for Thermography Consultation Patients.

__________________________________________________ _________ Printed Name Date

__________________________________________________ Signature CCIMThermPolicies1-11-18

CANCELLATION POLICIES

“Unfaithfulness in keeping of an appointment is an act of clear dishonesty. You may as well borrow a person’s money as his time.”