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CONFIDENTIAL PATIENT INFORMATION FORM

PLEASE COMPLETE THE INFORMATION AND SUBMIT THE FORM. THANK YOU.

OF THE EXAMS BELOW PLEASE LET US KNOW THE DATE OF LAST EXAM AND PLEASE SELECT IF TEST WAS NOREMAL [NOR] OR ABNORMAL [ABN]

We Do Not Participate With Any Insurance Providers And As Such, The Integrative & Functional Health Genter And THCE Does Not Accept Not Medicare Payments. We Will Not File Any Medicare Claims or Provide You With Any CPT Or Diagnostic Codes For You To File On Your Own With Any Insurance Carrier.

The following guidelines are now required for all patients, their families and friends who may accompany them to their appointments:

1. All new patient paper work needs to be completely filled out before your appointment or we may need to reschedule your appointment. This can be downloaded from the website www.thcehealth.com then click on forms. Please make sure our staff gives you the password at the time your appointment is made. You can then fax or scan and email these back before your appointment.
2. We ask that you get your medical records to us as soon as possible before your appointment, or at least have them with you on your initial visit. Reports such as blood, CT/PET/MRI, cardiovascular work ups, pathology biopsy results over the past year.
3. Patients on the first visit should have all friends and/or family members with them [and please let us know in advance the approximate total number attending—everyone in the consult will have to be members as well] so any and all questions and concerns can be addressed at one time.
4. If you have children under the age of 12 years old, we ask that you have an adult to watch your children in the waiting room, but not in the IV room, or any treatment areas or during any consult.
5. Because we work with many cancer patients, we ask that you not bring meals into the clinic. Often the odors can be very troublesome to those on chemo treatment or others that are over sensitive to various odors. If you need to eat something you can have raw vegetables, berries, cherries, apples or an energy type bar. If it is necessary that you have a full meal please schedule so you can eat either before or after your treatment.
6. We also ask for all patients not to wear strong fragrance when they will be in the clinic. The same reasons apply here as those for food odors.
7. Please keep your cell phones on vibrate while in the IV room or during consultations. You obviously can take any emergency calls that may arise. We request that you not conduct business or numerous routine phone calls while in the IV room.
8. If you are accompanying a patient who will be getting an IV, we respectfully ask that if the IV room is full and if you are not receiving an IV yourself, please allow the patients to have a chair to sit for their IV.
9. Any returned supplements must be pre-authorized and will be subject to a re-stocking fee.
10. Any missed appointment without at least a full 24 hours' notice you will be charged for. Please, also understand, if you are more than 30 minutes late you may either have an extended wait to be seen or we reserve the right to re-schedule you for a later date. Occasional emergencies are understood.

The purpose of these guidelines is to allow our patients a consistent atmosphere in which they can relax and have a pleasant and peaceful place to concentrate on improving their health.

We thank you in advance for your understanding and cooperation.

GENERAL INFORMATION AND GOALS FOR MEMBERS ONLY

As you already know we do not accept insurance and do not give you any information for you to send to your insurance company for reimbursement. By doing this we can recommend what you actually need, not what the insurance will reimburse. Typically, most insurances do not reimbursement for integrative care even is they say they do. When we recommend lab work of any kind (blood, saliva, hair, etc.) we prefer to order it and have it go through us. That way the lab, techniques, reference ranges and chemical agents are consistent so we can make better history comparisons with each new retest. Also, this way your follow-up report of findings are automatically included in the price we charge for the labs. However, if you decide to have someone else do your labs for insurance or other reasons then there is a charge to go over your lab results. The charge will be $100.00 for each 15 minutes (minimum charge will be 15 minutes). The time involved could be as short as 10 minutes or up to over an hour to review and report your results, protocol and answer your questions. Please consider this well before choosing. One or two occasional follow up short questions/answers will usually not be charged to you. If your question/answers are longer, more frequent and/or complicated, then you will be informed of any cbarees before we talk.

If you purchase your nutritional supplements from someone else or a different product than we have recommended then we highly recommend that you follow-up with the person or company you purchased them from or call the company to ask any questions. If you use what we have recommended and get them from us then we can answer short questions about the supplements. If you have any issues about a supplement quality then we call the company for you, usually at no charge within reason as described above. Also let us know if you add anything on your own that we have not recommended. Sometimes natural extracts, vitamins/minerals will interact and may even cancel out the desired effects.

Most of our beginning protocols will continue for about 30-90 days unless we change them because your personal needs are different. You should schedule and come in every 4 weeks during these 90 days for a follow up and any questions you may have. If you have a brief question or two before your monthly visit then most likely there will be no charge. Again, if the questions are long and/ or numerous then the above charges will apply to in office visits or phone conferences. Once your condition has progressed to the maintenance phase and the acute phase is over then your visits will be scheduled every 3-6 months unless something develops earlier.

We want to serve our patients to the best of our abilities and be fair to everyone involved. This is the reason for the above explanation and we sincerely hope you understand, because we do believe that Personalized Care Is Our Specialty and the only way you should be treated.

INFORMED CONSENT FOR ALL PROCEDURES/TECHNIQUES USED AT THCE.

CARE ENTITIES (THCE) and specifically to all healthcare practitioners Licensed & Registered by: Tribal Health Programs & Clinics A Private Tribal Membership Facility and all staff members working under their direction and orders to perform various procedures recommended by them. I understand that the Integrative/Natural Technique is accepted only by a minority of the medical community. The majority of the medical community feels that Integrative/Natural techniques for most health conditions has little if any benefit at all. The majority of physicians and insurance companies consider such techniques "experimental". This is why we do not take any insurance and we do not write letters to any type of insurance companies on behalf of the patient to help get reimbursement, especially when cancer is involved. I have been advised that the (THCE) health care providers believe that one or more of the below procedures/techniques will have positive clinical benefits in my case. I have been informed of other treatment approaches that are often used by main stream health care providers for my condition(s); these include but are not limited to prescription medications (including chemotherapy), surgery, angioplasty, bypass surgery, stents, radiation and other approved and unapproved medical procedures.

More specifically, the mission of our Health Center is to provide our members with the highest level of quality care and a number of effective Integrative/Natural methods and techniques available. We support our members’ health condition(s), and not merely the symptoms they may experience. Our Licensed Health Center understands that wellness has many dimensions and strives every day to stay on the leading edge of new technology. The Licensed Health Center provides a broad scope of Integrative/Natural and conventional care along with advanced technologies to discover all aspects of a member’s health concerns and provide the most effective means of support at an affordable fee. More specifically, the Licensed Health Center offers the following: Musculoskeletal Care, Diabetes support, Heart Health Support, Chelation and other Specialized Formulas, Vitamins and Minerals, Vitamin C, several forms of Oxidative Therapies, Toxic Metal Removal, Mercury Removal, Phone Consultations, Personalized Health Consultations, Dietary Recommendations, and various S.O.T. (Short Oligonucleotide Therapy) Techniques, Infiniti HUC Stem Cells, iPSC stem cells, Plasma), Chi Machine, Allergy Support, Plethysmography, Naturopathic Care, Blood Work, Oxidative Technique, Pulse Electro Magnetic Frequency, Zyto Scan, Bach Flowers, Herbal Support, BCX Resonance Technique, Hormone Support (Male and Female), Nutritional Support, Homeopathy, Various Healthy Aging Techniques, and Healthy Screening for Cancer. These and more are offered to all members for optimization of health and well-being. This is what we call Personalized-Patient Centered Care. The above list is subject to change as we may add or discontinue various techniques over time. Please ask for more detailed information on any of the above therapies you may be interested in.

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I understand that the benefits of all the above Procedures/Techniques are much greater if I follow a healthy lifestyle, (no smoking, weight control, proper exercise, proper diet, limited alcohol use and others). I understand that an initial series of treatments are anticipated, and that these treatments may be extended over a number of months (3-12). I have been informed that any or all of these procedures/techniques may need to be repeated from time to time in the future in order to maintain the benefits. I understand that it is my option to stop any of these recommended health protocols at any time without incurring any further expense after I have been directed that such treatment be discontinued.

If I have suffered from any previous organ disease or damage, and any cancers, I agree to execute a medical release so that all previously identified medical records of mine may be obtained from previous treating physicians, and I have disclosed openly any known organ disease or damage, and any cancers. l understand that if I have a history of tuberculosis. Chelation Technique may reactivate arrested tuberculosis, and I agree to inform the doctor of any occurrence of this disease. I understand the nature of the proposed procedure/techniques and the risks and dangers have been explained to me to my full satisfaction. I also acknowledge I have not been asked to discontinue care with any other health care providers. I further understand that it is entirely my own responsibility to consider the advice and recommendations offered to me by my fellow members and to educate myself as to the desirability of same.

Many if not all the above techniques/procedures we offer have not been evaluated or approved by the FDA and is not intended to diagnose, treat, cure, or prevent any disease.

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It is very important that you let us know immediately if you notice anything unusual, including any and all the above ­mentioned potential risks and side effects while in the office, at home or out of town. If it is an emergency, you will need to get to the closest emergency room immediately. Then, please call or have your contact person call us as soon as possible, even if to just leave us a message regarding your concerns and a way to contact you.

I also acknowledge and understand that THCE does not participate in any way with any insurance companies. I also understand that all Licensed Certified Traditional Tribal Health Care Providers (CTTP, CTTH, STH) have opted out of all insurances and that Jimmy W. Dailey, MD has also opted out of Medicare as well. We do not file or provide any forms or diagnostic codes to file for any insurance reimbursement. The office staff will have you sign our STATEMENT OF UNDERSTANDING GUIDELINES REGARDING THIS.

**The above highlighted and bold symptoms are for the IPSC stem cells only!

All Services of THCE Are Available to Members Only and Memberships Must be Renewed Yearly!!

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