Dr. Timothy R. Morris
Naturopathic Doctor and IFM Certified Practitioner
Welcome
Dr. Morris is looking forward to working with you. The following prompts will guide you through the intake paperwork.
Patient Information
Contact Information
We will NEVER share or sell your contact information; we will not be a source of spam.
I agree to be contacted regarding my care
By Phone:
By Email:
By SMS/Text:
Emergency Contact
Responsible Party
Primary Care Provider (PCP)
Referral Source
Insurance Information
This information is for conventional lab billing purposes only.
Dr. Morris does not bill insurance for consultations.
Informed Consent
- Treatment: I authorize Dr. Morris to provide diagnosis and treatment, including diagnostic procedures (labs, imaging), lifestyle counseling, prescription medications, and nutritional/herbal supplements.
- Risks and Participation: I understand that there may be risks associated with conventional and alternative healthcare approaches employed by Dr. Morris. I acknowledge that I have the right to ask questions about the risks and benefits of my treatment during consultations. I understand that I am responsible for the consequences of my decisions to modify, add to, or discontinue my treatment.
- Remote Care: I understand consultations are remote, and I agree to maintain regular in-person contact with a licensed primary healthcare provider (PCP) for physical exams and routine screenings. I accept that consequences from my failing to seek routine in-person care from a PCP is my responsibility.
- Privacy: My medical record will be kept confidential per HIPAA regulations. I understand it may be shared as required for insurance, payment, or by law.
- My Responsibility: I agree to provide full and accurate information to the best of my ability. I understand that incomplete or inaccurate information can cause adverse effects for which I will take sole reponsibility.
- I Understand: that my form data will be temporarily stored on this device (in the browser’s local database) to protect my progress while I complete the 9 sections.
- I Authorize: the final submission process to delete all locally stored form data from this device immediately after a successful transfer to the clinician’s secure server.