Natural Medicine for Autism in San Diego

Pediatric and Autism New Patient Information

Thank you for choosing Dr. Nicola as your healthcare provider. She is dedicated to making your experience a most satisfying one.

The information contained in this form is necessary in order for us to complete your in office file and for our participation in your health care.

If you are not comfortable completing this information online please click the link to Download the New Patient Paperwork - which you may then print and email, fax, mail or bring with you to your appointment.

Patient Name*
PrefixFirstLastSuffix
Home Address*
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Birth Date*
Primary Phone*
Cell Phone
Email*
Skype ID
Employed by
Occupation
Preferred Name
Who Referred You To Our Office?
Who is your medical insurance provider?
- HMO
- PPO
- None
- Other
In case of emergency contact:
Name
FirstLast
Relationship
Address
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Home Phone
Work Phone
If patient is under 18, please list the parent(s)/guardian(s) names:
Please list the patient's parent/guardian first and last name.

Policies and Procedures
Nicola McFadzean, N.D.
Office Policies and Procedures

Hours:

Mondays, Wednesdays and Fridays 10am-5pm (PST). Office visits and telephone consultations are by appointment only.

Fees:

Initial consultation (45-60 mins) - $325.

Follow up (20-30 mins) - $165.
Brief follow up (10-15 mins) - $85.

Appointments:

Appointments are scheduled by telephone or email. Please leave possible dates and times. The staff at RestorMedicine will confirm your appointment time with you.

Payment is due at the time of your consultation. Methods of payment are: Visa, MasterCard, Discover, check, and cash.

First appointment: All initial paperwork must be completed, signed, and received by our office preferably 2 business days prior to your scheduled appointment. Please fax or email these forms (as single PDF file if emailing). Also send an electronic photograph (JPEG format) for our medical records.

First appointment: If paying by check for a phone consultation, the check must be received in advance of your consultation. If paying by credit card you may be asked to provide your credit card number at time of scheduling to hold the appointment.

Follow-up consults may be scheduled in 15, 30 or 60-minute blocks of time.

Consultations with other healthcare providers and/or any research requested by the patient are billable services and will be charged at the hourly rate.

Scheduled consultations that include review of lab tests require that laboratory test results be received at least 24 hours prior to appointment.

Medical Letters:

Medical letters to schools, insurance companies, disability, etc. are a billable service. If these items are requested there may be an additional charge based on the time involved at the hourly rate to complete your request.

Office Consultations:

Please advise the doctor if wheelchair access is required.

Phone Consultations:

Dr. Nicola will call you at the time of your scheduled consultation. Please allow a 10 minute window from your appointment time to hear from Dr. Nicola.

Dr. Nicola requires patients outside of the USA to call the office at the time of their scheduled phone consultation. If this is not possible, then phone consultation phone bill charge will be billed to the patient. Dr. Nicola also uses Skype (user name is NicolaMcF).

Cancellations:

Patients who forget their appointment or cancel less than 24 hours prior to the appointment will be required to pay 50% of the missed visit fee. Please understand that a missed appointment could have gone to another patient. New patients may be required to provide a credit card number when their appointment is scheduled to hold their appointment time.

Questions and Follow-up:

Please direct e-mails, faxes or letters regarding you or your child’s care to info@restormedicine.com. Questions must be brief and concise. Dr. Nicola will determine if a phone or office consult is needed to answer your question(s). Otherwise, she or an administrative assistant will respond to your inquiry. When leaving a voice mail message, please be brief and concise and always include your name and phone number, including the area code.

Please Note: We try to accommodate questions regarding treatment clarification at no charge. Simply put, if you have a quick question about a supplement or diagnostic test we recommended or a therapy reaction you may be experiencing, then by all means contact us. However, if the response to a question you submit requires doctor research and/or review, you may be billed for the time involved at the doctor’s hourly rate, or requested that you schedule a phone consultation.

Follow-up Office Consultations:

We generally recommend that all patients minimally have an office consultation with Dr. Nicola every 6 months.

Insurance:

Dr. Nicola does not accept any insurance plan, nor bill insurance on your behalf. She will supply you with a “superbill” or medical receipt that you can submit to your carrier for reimbursement. She makes no guarantee of payment or reimbursement by your insurance carrier.

Dr. Nicola does not accept insurance liens, assignments, or any reimbursement from your insurance carrier.
Acceptance of Policies and Procedures
I have read and agree to the policies and procedures detailed above.*
- Yes
You must answer 'Yes' to this question in order to proceed with the online form submission.
Patient Name*
PrefixFirstLastSuffix
Date*
Electronic Signature of Patient or Responsible Party*
By typing your name in this field you are electonically signing.
If signed by party other than patient, print name:

Pediatric and Autism

Need To Schedule A Consultation?

Printable Forms

Submit New Patient Paperwork Online

Pediatric and Autism New Patient Information

Step 1 of 6

In case of emergency contact:

Policies and Procedures

Acceptance of Policies and Procedures

Pediatric Health Questionnaire

Autism Spectrum Disorders

Other Health Issues

Digestive Health

Antibiotic History

Home Environment

Mother's Pregnancy and Labor

Mother's Medical History

Family History

Vaccination Status

Medication Usage

Diet

DAN! Therapies

Additional Information

Contact RestorMedicine

Schedule An Appointment

Dr. Nicola’s Latest Articles