Naturale Alternatives, Inc.
Ernest Huhta, Jr. CMAT & Associates
Muscle Therapy, Acupressure, Electro-Body Therapy, Reflexology
19 Third Street, SE, PO Box 264
Menahga, MN 56464
Phone: (218)564-4200
Fax: (218) 564-5711
Lakeside Sports & Pain Clinic
21920 Minnetonka Blvd.
Excelsior, MN 55331
Phone: (612)205-4258
Alexandria Area
115 3rd Ave West
Alexandria, MN 56308
Phone: (218)564-4200
Sauk Centre Area
33375 US Hwy 71
Sauk Centre, MN 56378
Phone: (218)564-4200
NEW CLIENT INFORMATION FORM 2015
PERSONAL INFORMATION
Full Name: _______________________________________________________ Male or Female (circle one)
Address: ____________________________________ City: _______________ State: _______ Zip: _________
Cell Phone Number: (
) ______________________ Home Phone: (
) ____________________________
Date of Birth: _____________________________ Occupation: ______________________________________
Email:
_________________________________________________________________________________________
How did you hear about us? __________________________________________________________________
IF CLIENT IS A DEPENDENT or UNDER 18 YEARS OF AGE:
Parent/Guardian: ____________________________________________ Phone: ________________________
Address: ___________________________________ City: _____________ State: _________ Zip: ___________
Please Initial: _________
This parent/guardian is responsible for treatment fees.
HEALTH CONCERNS
Please notify receptionist if you are seeking our services due to a recent automobile injury or work injury
What are your current health concerns? _________________________________________________________
How did these problems start? ________________________________________________________________
Other care received for this problem: ___________________________________________________________
Referring Physician: ___________________________________________________
I understand that the services rendered by any therapist of the Naturale Alternative Clinic is for therapeutic purposed only, and that
the care received does not constitute diagnosis or treatment of disease and chiropractic, medical, orthopedic, physical therapy or
other similar modalities. I also understand that I am wholly responsible for my own health. Services provided by the therapists of
Naturale Alternatives are received by my request. I clearly understand and agree that all services rendered to me are charged
directly to me and that I am personally responsible for payment.
Signature_______________________________________________ Date ____________________
(Please
read and sign the back of page also. Thank you!)
NATURALE ALTERNATIVES, INC
Your Complementary and Alternative Health Care Bill of Rights
Statement of Credentials
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You are treating at Naturale Alternatives, Inc. at one of the addresses listed on the front of this form.
You may be treated by one of the following therapists employed by Naturale Alternatives, Inc.:
Ernest Huhta, Jr., CMAT-EASP (certified Massage/Muscle and Acupressure Therapist-Electro-Acu-Scope Practitioner)
Barbara Sturos-Huhta CMT (Certified Massage Therapist),
Janelle Lake, LMT & Peggy Keranen, LMT (Both are Licensed Massage Therapists, Licensure from Arizona)
Hannah Huhta-Rintamaki, MT (Massage Therapist), Lynn Impola, MT (Massage Therapist)
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Excerpt From Minnesota Statue 2000, 146A.11
“The State of Minnesota has not adopted any educational and training standards for unlicensed complementary and
alternative health care practitioners.” This statement of credentials is for information purposes only.
“Under Minnesota law, an unlicensed complementary and alternative health care practitioner may not provide a medical
diagnosis or recommend discontinuance of medically prescribed treatments. If a client desires a diagnosis from a licensed
physician, chiropractor, or acupuncture practitioner, or services from a physician, chiropractor, nurse, osteopath, physical
therapist, dietitian, nutritionist, acupuncture practitioner, athletic trainer, or any other type of health care provider, the client may
seek such services at any time.”
Your Treatment with Us
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As therapists, we can provide you with a variety of attended manual therapies and unattended electro therapies (listed
below in fees section) to address muscular pain and dysfunction.
We reserve the right to not treat you based upon your presentation of concerns and issues. This may constitute a referral to
your primary doctor, chiropractor, or an emergency room visit, etc. We also reserve the right to show your client
information with doctors on our staff, but with your permission.
You may expect courteous treatment, free from verbal, physical, and sexual abuse.
Your Rights
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The right to complete and current information about our assessment and recommended service provided you, and the
expected duration of the services provided.
The right to reasonable notice of changes in services or charges.
The right to be allowed access to your records by request.
The right to refuse services or treatment at any time,
The right to choose freely among available practitioners, and to change practitioners after services have begun.
The right to a coordinated transfer when there is a change of practitioners.
The right to assert your rights without retaliation.
The right to file a complaint with the Office of Unlicensed Complementary and Alternative Health Care Practice, Minnesota
Department of Health, Health Occupations Program, PO Box 64975, St. Paul MN 55164-0975; Phone: (651) 282-5623.
Fees for Service
 You can expect the approximate range of fees depending on therapies needed: 15-minute session: $20.00-$60.00;
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30 minute session:$43.00-$135.00; 45 minute session:$64.00-$185.00; 60 minute session: $84.00-$200.00+
Fees can include one or more of the following therapies: manual/sports, attended and unattended electro-therapy,
neuromuscular re-education, myolymphatic drainage, myofascial release, trigger point, stretch/ROM, reflexology, and
heat.
We Accept payment by cash, check, or credit card at time of service.
We are not a provider for any insurance companies, Medicare, medical assistance, or Minnesota Care programs. We
cannot submit your charges on your behalf. However, you can submit your charges on your own with a receipt. If you plan
to submit to your insurance company, it is recommended that you obtain a written prescription and diagnosis (statement of
medical necessity) from your physician before treatment begins. Consult your insurance policy for coverage details.
Notice of Privacy Practices
 I give consent for my protected health information (PHI) to be used/disclosed only for the purposes of carrying
out treatment and payment.
 I have the right to review the full privacy notice (posted in clinic; copy available on request from front desk).
 I may request restrictions in uses/disclosures of PHI in writing.
 I may revoke this consent in writing anytime.
 I have received and understood the above complementary and alternative health care bill of rights and notice of
privacy practices.
Signature: ______________________________________________________ Date: ______________________